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,SAN ,IOAQtiIN COUNTY ENN7WONNIEN'TAI., TTEALTH DEPAWI'MEN1' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C' <br /> OVIINER I OPERATOR <br /> Vill x,t L L G CHECK if BILLING ADDRESS El <br /> 1--F—.ACILITYN--AME <br /> h-e YY1 I tae Is <br /> SITE ADDRES$ ? (J�� .r �L�a(-� rn Tq <br /> 7(?131 Stroel Number Directlun StreetName CitZI Code <br /> HOME or MAILING A(D�-DRESS If Different from Site Address) <br /> IJ Ypal( �� �� Street Number Street Name <br /> CITY Y-fYAoh-f– STATE ZIP , !S-3 <br /> PHCNF 91 ExT• APN# LAND USE APPLICATION# <br /> t (q► Q — g$ 212-1604,7 PA-1700072 (SA), S00011318 <br /> PHONE#2 Ext. BOS DISTRICT LOCATII��CODE <br /> CON'T'RACTOR / SERVICE REQUESTOR <br /> HEQUESTOR CHECK If BILLING ADDRESS® <br /> Gigi Beene/Mike Bonilla <br /> BUSINESS NAME PHONE# ExT. <br /> FULLMER CONSTRUCTION ( (909) 969-4141 <br /> HOME or MAILING ADDRESS FAX# <br /> 1725 S. Grove Ave. I ) —1 <br /> CITY Ontario STATE CA ZIP 91761 <br /> IilLi,l\'(:r ACtiNO�VLEDGE><IF.NT: I, the undersigned prapert}° or business o��'ncr, operator or authorized agent of same, <br /> ac!cnnwledgc that all site andror project specitic INVIRON�tF..NTr1L IiFALTIi DEI'AkTMEN"1'hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAOUIN <br /> COON"1"t' Ordinance Codes,Stann:;k <br /> d STATE <br /> d FE = tL laws. 12/11/2020 <br /> APPIKAN'l"S SIGNA'T'URE: DATE: --.. <br /> t'I:urF:ttry!I311S1\ES5 C)1V\ER❑ FRa itln�Ac:i:tt ❑ O'ftlF.tt Al;TitoRl7.Fr)AGE\1'� Contractor <br /> 114PPLICAArT is not the BILLLVG PARTY,progl'of authorization to sign is required Title <br /> AU'T'HORIZATION TO RELEASE INFORMATION- When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical dat and/or environmental/site assessment <br /> information to the SAN JOAQUIN COLIN F%' Et4vIKONd9GNTAL HI�AL:rti DEPARTMENT as soon as it is available and at the same time it is <br /> provided to nmc or Illy rcpr•cscnttrtivc. <br /> TYPE OF SERVICE REQUESTED: f IG,41 (4)(-J< (�f C'1� <br /> C0"MENTS:SJrJL`- `J�oWD7yS' lat of 0(;,{q1 li/zs" )(9 r,�,i�' bV pct& bf reVIV*/ P�1�r ( SYS Ply-i <br /> RE�� <br /> �D <br /> DEC a 2 2020 <br /> ACCEPTED BY: = T_ 1 L— EMPLOYEE#: <br /> EMPLOYEE#: DAT , <br /> I AssIGNED TO: <br /> Date Service Completed (if already completed): SERVICE CODE: `y ,? P I E: `1_2 <br /> Fee Amount: _s i,-! Amount Paid ! L� J Payment Date –12 2 <br /> Payment Type Invoice# Check# Received By: <br /> SR FORM(Golden Rod) <br /> EHD 46-02-025 <br /> REVISED 'I 1!17/2003 <br />