Laserfiche WebLink
SANJi7AQUIN COUNrf'V riaNV RONNIEF, I AL llri SAO%II E, PAlt'7`MENT <br /> SERVICE REQUEST <br /> Type of BuMness or Property FACILITY 10 # ;SERVICE REQUEST # <br /> 0159' <br /> tADo. o3t � � at- 1 1 '� <br /> OWNER I OPERATOR _ _ . - l;ft�ClCYft3iLLING' ADCIiieSS ® <br /> Sh64004 cit: ProduvLa : £ts Terminal nPt a.tdt. . RiChard Btonsdn <br /> FA61LITYIIAMIE $tp lsttrit Tartiiii l <br /> SiTEAbdR Ss 351a L <br /> lavy pi; 9-520 <br /> 51 ae}: r6ri j i t+ - <br /> -- -- - -- -��1LEet : u i c Sitter ] ane Cl Z Go u <br /> ROME or Mow ADDRESS (if Dif feWiit fratil Site Addross) <br /> Sir&et Nu15i13a1' SlrBc1 Nanie <br /> CITY SYA18 zip <br /> ('HON€ l1t OxT APN # LAW Ust A0pucAtiot4 <br /> 310 ). 8116w605 ,65 <br /> PHONE Epp 008 01571iloY LOCATION CODs <br /> c �- _ - _ 06 001ot <br /> . CONTRACTORI SERVICE RE UESTO <br /> Ruciuesmz <br /> Ryan CHECK ifAILLIN&AgOVEss <br /> BUSINESS NAME iiaki� tiyeu:ry ;Tnc : -- - --- — pri7i 826=0325 €xT. <br /> l- omE or IUTA£L£NG ADDRESS = ----- - FAX # <br /> 8.281 C.OnTlo wealth Ave <br /> t ' 7 . <br /> CITY Huelva Park - - --- -- STATE CA ZIP 901;31 <br /> BiLLIN+GNDyLXDtY NII;IVTs I , Elly UililCt'Slgileij proper <br /> ty of busluess owners operator of atitholilaed agent of saillef <br /> acknowledge that all site widlo€ Project speGllfc 1 NVIROltiMENPIAL 1' UALTH ORPARTMr'NT hoildy Charges aSsouiated with this pr(Iject <br /> or ackligj will be !tilled to tele or my business :`lS Identified oil this fi71'£n, <br /> i also certify that -1 have prepared this application and that tilt workfo .be perfo£nlled will be done 111 acco3'Clanoc With all SAN JOAQUIN <br /> COUNTY L.IP&11(fltc�0+ Cotlft, SNIIIC� Wds TAT>i .1 d F110BSRAL I£lwS. <br /> APPLACANT'S 81GN ►`rUl DATE; Mar . 2 , 2021 <br /> . Pfto1`Euy / ij su\,Fs5t,lw FA © OPERATOR INIKINAfER 0T-11ErtA1171io]£tul) -AGENT <br /> Ifrf�'j#��ti:�fn�r r`.� nit t/ir3131LtJi,�jt' get(�Z3',.,t»'v>7,�`c��'rrrfilior�Ranti�tr tet' si�grr rs• r•�grrii�[l ri�tay. <br /> UTHC?RiZATION TO At I ,EASIJ TNrf1It111A116N: When altptic6le, is the owner or operator of the property located at the <br /> above Site address, licreby authorize, tile felCaSG Of filly All(] 011 1•Cstllts; geolechnical ilat£i andlor assessment <br /> itifint ll£ltiolt to tilt SAN JOA(lllliV COLJN TY $NViRONN4Ft4TAL HIrALTH EI?ARTh7ENT aS Sooll as itis: axtailable aiid at the sante ti)ile it is <br /> Provided to dile Or my rel resentativok <br /> TYPE oFSmvinRioi11=sum USS' Cly 8ute its Place N Y114 <br /> < <br /> , 6 <br /> 1 SAN J q2021 <br /> t h�q0 pM <br /> 4 oUNry <br /> q C <br /> AccEPTED 13Y; 1540PLOYEE #: DATt tS�S (p <br /> � - _. ----- — — - <br /> ASSIGN90TO: � EMPLOYEE #: <br /> Pate service completer 1t alreacij? cblti etett} St RvtcP coni; � ,� P I t=i250 <br /> Foo Anioutlt. O Amolint Pah Payment Date <br /> 2_ - - - <br /> PaytnentTylSo I J� invoice # ch6ok # L�L� SCS Reeei d By < <br /> i HD 4"2-025 SR FORM Golden Roil) <br /> REVISED 11/1712003 <br />