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Type of Business or Property FACILITY ID # SERVICE REQUEST 9_-'-.: <br />OWNER IM <br />Q l / rry f z CHECK if BILLING ADDRESS UO <br />FACILITY NAME �/ v <br />SITE ADDRESS <br />6OLVI'll 19 8r'l.-'P-+Y130 l.(Y'�r 1j f '�-c-D,-� i.l �}iif....-i��p7 •t� <br />i Fes, -'$ C..i t.. <br />(..rXb(/ tt <br />!Sir <br />6'I <br />- <br />t- 5trcatRumber <br />D tion <br />�"Np <br />' N-11 <br />MAY 05 01 <br />SAN JOAQUIN COUN'T'Y ENVIRONMENTAL HE <br />�- <br />DEPARTMENT <br />01.1 [�i STAiE>�({ zip 5"'I?" �t{"'f• <br />I I <br />SERVICE REQUEST <br />PHONE#2E} (( Exr• <br />BOS DISTRICT <br />LOCATION CORE <br />1l'.- r t .* Received <br />Payment Type ,/t» _ €nvoice# Ch,a #(!f6)L Cj /S �.l Y <br />'ui '. if�•r <br />Type of Business or Property FACILITY ID # SERVICE REQUEST 9_-'-.: <br />OWNER IM <br />Q l / rry f z CHECK if BILLING ADDRESS UO <br />FACILITY NAME �/ v <br />SITE ADDRESS <br />6OLVI'll 19 8r'l.-'P-+Y130 l.(Y'�r 1j f '�-c-D,-� i.l �}iif....-i��p7 •t� <br />i Fes, -'$ C..i t.. <br />(..rXb(/ tt <br />!Sir <br />6'I <br />- <br />t- 5trcatRumber <br />D tion <br />�"Np <br />' N-11 <br />DATE: ri-I� �fn <br />ASSIGNED TO: Y1 Drnn MaIA Yr7 <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street `dumber i?} <br />01.1 [�i STAiE>�({ zip 5"'I?" �t{"'f• <br />I I <br />P Op;_'i Exr• APN# LAUD USE APPLICATION#fill <br />T <br />PHONE#2E} (( Exr• <br />BOS DISTRICT <br />LOCATION CORE <br />€REQUESTOR ! •.a �' i'�S�s � {,,-^^� "� CHECK If BILLING ADDRESS <br />BUSINESS NAME PHONES# EXT. <br />HoNIIEOrMAILING ADDRESS �{/!)J <br />CITY <br />Id s �4`. p <br />- <br />FAX 1 <br />—STATE zip 'f✓ -<7 <br />BILLING ACMNQWLEIDFIa NT-. 1, the undersigned property or business owner, operator or authorized agent of sa1TDe, .. <br />_.__._� actino ledge ihatalLslxe_aticll4.r_pF9j c ecifc EN_ViROtvuRwAL_HEALTH DEPAR mEN'F hourly. char S associated_rvith this project <br />car activity will be billed to nae or my burn6—sas!d9eIntified on this form. <br />I also. certify that I have prepared this appIieati i and that the work to be performed will be done in aecordance with all SAN 7OAQUIN <br />CovtstY Or•dinonce. Codes, Stand ds, TAT and ICED= . eAv-s__. <br />r <br />APPLICANT'S SIGNATURE: <br />PROPERTY/ BUSINESSOWNCRD ,•. i�EERAT—a'IAtNACER El 0-rHERAUTHORlZFDAGEi�'.F <br />If APPL1C;INT is not the i31LLING f'rfRTY proof qfo athorization to :sign is required Title <br />•A.LI1'flORI ATION ISA RT1€ A €Nk�ft€tlA`i IC2N: When applicablc, 1, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all reSURS, geotechnical data andlor cm+ironlnental/site assessment. <br />information t0 the SATd IoiQUIN COUNTY ENViRO*;RkENTAi, HEALTii Di;PARTMENT RS SOURS it is available and at the same time it is� <br />provided to n).e or Div representative. " }f <br />TYPEOFSERVICE R.EoUEESTED: <br />COMMENTS: .e-'..:- �"��X...•"L��3 fw-i.-!`� CJ`�r..'° l ,6G-� ✓`,,: / f `.•'!{.�jT� <br />� L ��� � G�'t". �• l,.`• -t �. , �1��:r.�O�Q <br />6OLVI'll 19 8r'l.-'P-+Y130 l.(Y'�r 1j f '�-c-D,-� i.l �}iif....-i��p7 •t� <br />i Fes, -'$ C..i t.. <br />` �� `.L.{pNvy�c� <br />Ifl <br />�L -r• 41.3 <br />6'I <br />- <br />ACCEPTED By, <br />EMPLOYEE#: <br />DATE: ri-I� �fn <br />ASSIGNED TO: Y1 Drnn MaIA Yr7 <br />EMPLOYEE 4: <br />DATE: <br />Date Service Completed (if already completed): $EBV10ECofIE: 6'o /- PIE: f <br />Fee Amount: e �`�° Amount Pa"101.1; <br />3 _ D' / csf . C ) <br />€ a ment Date � �" r <br />y V � <br />1l'.- r t .* Received <br />Payment Type ,/t» _ €nvoice# Ch,a #(!f6)L Cj /S �.l Y <br />EHD 48-02.025 <br />REVISED 1'111712003 <br />l6 1 <br />SR FORM. (Golden Rod) . <br />