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JUL 17 2000 12:2130 HP LASERJET 32011 <br />i <br />• <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HFAL'i'll 9FI-ARTMFWr <br />SERVICE R.EQU"T <br />P•3 <br />Type of Business or Property <br />FACILITY ID N SERVICE REQUEST b <br />'s Siz �a31 a� <br />OwNc.JioprRATOR <br />1 to <br />Q+ECKtt <br />FKA rrr NAOt <br />•g► <br />ZJA Code <br />HOME or MAILING ADDRESS (Ir IYittergnt rraln Site Addresel <br />r <br />NY.v+.r ra 1 <br />CITY <br />STATE Zip <br />P,tor1E 41 Exr. <br />ApN g <br />LANo USI: APPUCATION a <br />( 1 <br />I•` •• 003 DIS7AtCT LOCATION COOL 1 <br />I 1 1 <br />CONTRACTOR l SCRVICE RE4 QUESTOR <br />RetauEsroR <br />( CN8'Ck if B(,LNrG A;IDRES1 <br />' BuglupssAlAMfAJ L+tg^ �i`>�`f'jOti1 PMONfit �� e 101 <br />xt. <br />How of MA WQ AODRI S3 r <br />FAx ° <br />CrrY R <br />eA a STA <br />BILL►1VG ACIQVQTdVLjDQf VII+NT, I, the undQrSigMd property OT bualaesa owner, uperutor or aulltorixdd scent or u(ne, <br />acliviiy 11 billed <br />le site and/or ybuproject SPec'ne ENVmR( ME-UTAL 148AUTI I DEPARTMEW lwurly charges n=ocjutvd wilh this project or <br />letivity will be billed to ttrc or my bttsincsg as idenlificd on this farm. <br />1 I also Certify that I have prepared this apphcatio and that the work to bt peArt►ted will be dans ill accoodallce with oft SAN JOAQ4jfa <br />uN7'Y orrlrgl►rrc•r Cvrler, Slgativrvls, 31/t`1'� d F •0 t. ��, <br />P 1CANT'S SIGNATUR& <br />batt:: <br />1 [arv/ 6uxurecv Uwt+e OrFe.�T()K M NAM ❑ Orttett AUMORj=o AcwT ❑ <br />I/11NMGrC�INS !s „p� �l,e Iri R �r pufojaurjlerirpllon /u sign (t required Tutu <br />' a Oe ad ON T 3F 1 ° 7' : Wften applilcabie, 1, the artier or operntar of (hc property Iucated at the <br />above Site adtlreea, hereby auth"i7c the MOW of any and ell tcscWts, <br />intormation to the SAN JOAQU1N COUNTY EnMttoNMENTAL 1' EALTll DEPAFUM sass goon a3 it ical 41813 sa ailablc end at tbeoi san ife a9 . <br />provided to ITte Or my representative. M� it is <br />Y <br />TYPE DF SlE WE REQutslED: S <br />Co"CWTS; <br />,v` 1 <br />GOVN <br />i SOP ON ENTA <br />; <br />SHEpL�H OEPARTM <br />APPRovEo or, , <br />ASSIGNt3o To <br />(�v EII�+ ori h: DATE: <br />i tato Service C plet0cl already eomptaterdl: <br />fit? Cow PIE. <br />F" Amount 2 ArnoLmt Paid —7 <br />6 --0-0 Rsjrmorlt Date <br />� Paymont TYP® irtvolee M' Chock # O •.-__ <br />(j f Recolvod By: <br />� EtiO 4g•t)T�J25 <br />RENIS[ b C_5.02 SERVICE REQUEST FORM <br />a0 39VJ lOd3C SV9 ZESTSZ860Z LZ:CT 500Z/8T/L0 <br />