Laserfiche WebLink
SAN.IOAQIITiY('OIINI'1' h;NVIItONNII„NIA1,III,A1,1l1 DF.VAItIMEN <br />SERVICE 1U."QUEST <br />Type of Business or Property FACILITY ID # <br />E.Dc.\ST11.9ist �1L Q _�,E L <br />OWNER / OPERATOR v... <br />TE sbcz p ZZ��-1►.)1 r� 6 M z.�C. rl r.� En CJ. L -(,C -. <br />FACILITY NAME <br />SITE ADDRESS t/O <br />FSIS,o2 <br />PAYS <br />MAY - <br />SAN JOA 2014 <br />SERVICE" REQ <br />CHL CA if t311 LINO ApgnESS <br />tGcvI ACJ LArN'€_ La TJ I, CAr q S2.44o <br />LHoME or MAILING ADDRESS (it Different from Silo Address) ' <br />_r__ . __ �_...._ .__-__.... Strop t Number front N Imo <br />r S rOIV E STATE TO< ZIP <br />PHONE fit Fxr <br />(2- 10) <br />PHONE #T <br />REQUE TOR <br />EXT <br />APN # LANE) Usr AnrtICATION # <br />Cri s- Izo- <br />80S QISTHICT ry LACATIONCgDE <br />CONTRACTOR / S11,RVIC'1,; Itl,;( tjj,:S 1'OIt <br />M <br />r14OME <br />tor <br />AME PHONE # Exr <br />AILING ADDRESSFAX� -t y ra Qtv F� ` Ti'iJ S TATEO ZIP ct( TOC -1 <br />1311,I,ING ACKNOWL,EDGEMENT': I, the Undelsl4ried property or business ownet-, oFleratur or aatl+o+irt'tl a);r:al of shine, <br />acknowledge that all site and/or project spccilIC F'NVIRONMi N I'AI IfI(Al ill DI PAR IMI NI hourly chargcs associated with this pro ect <br />or activity will be billed to me or illy business as idtntilied on this form <br />also certify that I have prepared this application and tlIat the ork to be perli,rmed will be done in accur�lancu with all Snnl JOAipnN <br />COE INTY Ordinance ('odes, Slan(t'arc%4, S I A I V and FIA II:RA aws. <br />APPLICANT'S SIGNA`('URH,: IM l a: �/,-zC) <br />PROPGR'fY/ (3lfSINGSSOWNER❑ Or`�'.i2��1'oi ANACEIR 0iiivit AiriiioR zui) A( I-WIM NG” <br />/f APP[J('AN7 !S not lire f3/l.l./r ; PiIRTY', �YUOlO� [tt1t11l1r% !lllurl t0 Sf;;n is r(irp(retj _Tuts• <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operatirr of"thc property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN J0AQ1IIN Ct UNI Y %N VIRONMENI'l Al t Al -ill DFVAR I MFN l as soon as it is available and at the Sarre time it is <br />provided to me or my representative. <br />I TYPE OF SERVICE REQUESTED: 1`-j5 \.( \�c l J Ci [ f.l $� � �►�iZb�/IA l PG_"7 L1 ft— <br />COMMENTS:pEv 1IC 1 S- 'r� t^.�N\/t�- Pl4G� SrG- J'CZ- <br />l=t"z,l�.�S' � �, fir �,J P � S ►'� �c�'� D lscot.�MG-�.�'' � C'�coN t�-r.�" D�rvC- <br />E4t.l ST► fJ � 5f--���rC. V'F'W � � '�uEGC2tCA t. '�vrt h�� T> 1 5±��<-t��..rL.S� <br />U 1''G pct? <br />ACCEPTED BY: EMPLOYEE #: 7 j <br />!/;q <br />DATE: <br />> D <br />ASSIGNED 70: hh �p/ EMPLOYEE #: �G/Jt > L <br />DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P I <br />f Z�C3 <br />�E: <br />r <br />Fee Amount:: �� 7 5 --._._ Amount Paid 3 75";OZj Payment Date v � <br />Payment Type -- __ <br />Invoice # Cfaeck # �l� � Received 13y: <br />E. ID 48 02-025 SR FO-RNI (Golden Rod) <br />REVISEC 11/1712003 <br />