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SAN JOAQ[000[Wry ENVIRONIVIEN'I'AL I-IEAIIs I)EPA R1IYIP:N"1' <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST It <br />f <br />�R-60037R% <br />J SR 004-/,? -93 <br />OWNER PER <br />"Y C-�7-CVJ <br />= -_ <br />`���Col 6�r LTC <br />---- l <br />CHECK If BILLING ADD SS J <br />ITY NAME. <br />Cate Service Completed (if already completed): SERVICE CODE: <br />Pi E:`3 r - <br />P1auu <br />L <br />tt( B�� 1�c� <br />I SITE ADDRESS <br />Invoice # 1 Check # <br />— <br />Received y: <br />_ — <br />L <br />o©OP"I"C4. <br />Street Numher <br />ection <br />Street Name <br />Cil <br />Zi Code___ <br />NOME Or MAILING ADDRESS (If Different from <br />Site Address) <br />1 <br />_ <br />CITY <br />Street Number Street Name _ J <br />STATE <br />ZIP <br />P:iotiE SFS E) <br />APN # - <br />LAND USE APPLICATION # <br />PHONE 92 EXT. <br />11 <br />BOS DISTRICT <br />LOCATION CODE -� <br />( ) <br />CONTRACTOR / SERVICE REQUESTOR <br />� REOUESTOR <br />h l�( ,.,Cl F-�rs D <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />'__ <br />f <br />PHONE# EXT, j <br />HOME Or MAILING ADDRESS <br />9. z-i,�io �� <br />FAx # <br />eo,(- 9,—�+9' <br />"Y C-�7-CVJ <br />STATE/'e ZIP 7SZ.0� <br />11 <br />BILLING ACKNOWI,EDGEMENT: 1, the undersigned pt-operty or business olvner, operator or authorized agent of' same, <br />ai:nnowlccige that all site and/or project Specific ENVIRONMENTAL 1-11W.I i Df:PARTMF.N'I' hourly charges associated with this project ,_ r <br />activity will be billed to tile or my business as identified on this Form. <br />I also certify that I have prepared this application and t he work to be perrormed will be clone in accordance with all SAN JOAQuir; <br />COUNTY Ortlrilunce Cortes, SltNxltr --ATI, all 1 1�L•DLiR laws. <br />APPLICANT'S SIGNXI'URE.. DATE• <br />Puoi,EUTv / BtISINESS OWN NRE] OPERATOR / 119ANAGFit OTIu:R AuTnoRtzr:D Aca:N'r ❑ ----- <br />1/'A PPLI CAN 7'is Hol the B1I.I.INC h l R7' Y p!'oof of authoriZotion to sign is required Tirle <br />AU"1'II0RIZA'I'I0N "I'O RELEASE, INE0I2MA'I'I0N: When applicable, I, the owner or operator or the properly located at t ;c <br />:dove site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />w.i'ormation to the SAN JOAQUIN COUNTY I:NVIRONMNNTAL I-IFAL1I I DEPARTMtiNT aS soon as it is available and at the same time it is <br />provided to me or my representative. -- -4 <br />TYPE OF SERVICE REQUESTED: r,,,(� I tO I ij <br />COMMENTS: <br />APPROVED DY: Cj Ll t <br />EMPLOYEE #: <br />C),3Z <br />— <br />DATE: C1 � j ag <br />ASSIGNED TO: <br />EMPLOYEE <br />DATE; n <br />� <br />Cate Service Completed (if already completed): SERVICE CODE: <br />Pi E:`3 r - <br />Fee Amount: -7 0 Amount Paid Gj — <br />Payment Date <br />tt( B�� 1�c� <br />Payment Type <br />Invoice # 1 Check # <br />0 <br />Received y: <br />r, -,D 48-01-025 SERVICE REQUEST FORN1 <br />"`.'ISED 6-5-02 <br />G- <br />