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SAN JOA011`: COIIiy I'Y I;l\�'F'�t.?-�'VEN"I 4l. HEA1:rII DEPAIZ'FMkE11- <br /> _ .'ERVICE REQUEST <br /> ?ype of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR ^ L <br /> fy /I17 1 / Q �-}z CHECK If BILLING ADDRESS <br /> FACILITY NAME 1� 'r / 1_/�/ ; <br /> SITE A2-500 DDRESS reet Number Dir <br /> Stection ��� Slre Name s'CIt Zi Cede <br /> HDM Or MAILING A7/DRESS (Jif{Different from Site Address) <br /> O / v Street Numb-r Street Name <br /> CITE SiATE ZIP <br /> '�/qy sr o <br /> PHONF.#1 EXT. APM LAND' USE APPLICATION# <br /> PHONE#2 ExT• 1[BOS DISTRICT �� LOCATION CODE <br /> 1201 q&4/- " �r 34�'S� <br /> CONTItACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> .tel/� f✓� <br /> BUSINESS NAME <!� �t �� PRONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> C:TY 6y— <br /> .2^ / STATE ZIP <br /> INUING AC'KNOWi,EDGE.NIEN'T: 1, the undersigned property- of business owner, operator, or authorized agent A same, <br /> ackno�.tiedge that all site an&or project specific FNVtR0N%II-ts'rAL IIkAt I i I DI:PAR I MI.N I hourly charges associated Stith this project or <br /> ..ctlt•il,, will be billed to me or my business as identified on this Corm. <br /> I also certit'y that I have prepared this ap lication and that the work to be perfornTed will be done in accordance with all S.NN J0lA0i'IN <br /> COUNT) Ordinantc Codes.Standar . 1F and He t___ <br /> aws. �t -1 "I ! t 3 2p� <br /> APPI")C'ANTU <br /> 'S SIGNATRE:_4 D'rv: <br /> PROPERTY/Bt siNfss Ott'RER❑ P•:R:\T R/:UANAGGR ❑ OTnER At-TIIORIzl?D AGE,,I <br /> 1J AP1'L1(.I.N T is not the B WA'G PARIT'.proof of authorization to sign is requirrr Tirle <br /> AUTHORIZATION TO RELEASE INFO RNIATION: 1Vhen applicable, 1. the owner nr operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotcclinical data and:'or environnte itaLsite assessment <br /> inforTnalion to the SAN JOAQVIN ('0UNT), E-NVIRONNIFNTAL HF Al i-ii DI;II:\R1NlLN I as soon as it is available and at the same time it is <br /> provided to me of nn represerttatite. <br /> TYPE(`E SERVICE REQUESTED: L)J e C, <br /> COMMENT$. <br /> RECEIVED <br /> „n,n <br /> 1 N AUG 2 3 R <br /> `•' ' <br /> SAN JCJAaUIN r_�`DLII <br /> ENVIRONMENTisl- <br /> /' �Ep1.TH DEf'AFt�" <br /> ACCEPTED BY: EMPLOYEE#: (, D�'I`' �✓ <br /> ASSIGNED TO: �r– A EMPLOYEE#: DATE: <br /> Date Service Completed (if already comp eted): SERVICE CODE: Z_ <br /> Fee Amount: 2 uAmount Paid Payment Date ;r L' <br /> Payment Type 11 Invoice# Check# I C Received By: <br /> ':HD 48-02-025 SR FORM(Golden Rod) <br /> r;'VISED 11/17/2033 <br />