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SAN JC)AQUiiN COUNTY kNA11* O* Ir111'1�IV's1 L MiAL'�Tkl T'��P.1�ItTNI�NT. <br /> SERVICE 9E Q°C V$T <br /> m Imp <br /> `type of Suelness or Property FACILITY 1 6 # SERVICE REQUEST # <br /> UST _ <br /> OWN Ek 10pERMR - - - - - CHECK If gLLINo AomResJ:1 <br /> 51,6.1 -3. OU, ftmducLs : U-A Te%minal Opleratot. R16hti .rrl Btonson <br /> FA.61LITYNAME stocktoil TOynixnal <br /> 51YEADtmms 3515 r}avy ar ataciiciTi , r A . �J � ? 63 <br /> -- - - - -- 5_iteei _ u SireerNNns cityZI Goc1n <br /> l- mE or MAILING Ar mtiss (if Different froM site Address) <br /> Street Number � SStruei Nam* - <br /> CITY. - STATE zip <br /> PRONE M LXT4 AIN # LANii USE A15PLtCATION <br /> ( 310 )- MvI60562 <br /> PHONE #2 EXT. LoCncinntcori - <br /> { 714) 826 03.52 3306 nt7 � <br /> - CONTRACTOR l SERVICE REQU STOR <br /> RaMe-STOR - - <br /> Ryan Hnit; rier t,)4ECKifBILt,MAborle88 El <br /> - — ---- Piioset3 EXT,, <br /> BUSINESS NAME LPsyn � Pea iy zisc : 71 � B�Ms0325 <br /> 14r1ME or Iii muNG ADDRESS -� - - -- - FAX,# <br /> 8..261 MGosfrnomalealth Ave <br /> CITY Buena Park STATE CA ZIP 906ii <br /> BILLING AI�I `Ni XVLIMl(ICyt,-Nl NTs 1, ilte undersigned property or business owner, operafor° or qutluntizecl ngerrt of snrrro; <br /> acknowledge that all site and/or ImIject speeitic Ery IRONMIiN'r'AE. TrlGill:'111 DEPARTNIRM' honrly charges associated with this pr(Iject <br /> or activity will be billed to we or my busluess as identified on this form, <br /> I also cortify that 1 havle prepared this application and that the work to be I uformed will be. done- iii accoi'tIanoo W3th . Sill SAN J()AQUINs <br /> COUNTY 0j ,(th?UM0, (inlet, ShYl ar°ds `rA'tr a tt Pet ERAL latus. <br /> APPLICANT`SSIGIVA`I'lIM j � � U;tmr, _ Mar , 2 , . 02 <br /> da <br /> PROPERTY/ )JrSIOMONVNER13 g C?ri:[ ATORINITA AGER <br /> Ij �IP1 '1ic:AA�T %sltaltheRiLuiyaPilo . 1itnoofoftttilli©iqz(tliott -lasigttist'egtilieiI Fids. <br /> AUT—HQHiZA'r10N' TO REL,EASEIN1IORMAT1W Wien appiicrible, T, the ownei° or operator of the property ideated at the <br /> above :site address, hereby authorize the release of any Mid all resultsi geotocliulcal data andlor @liYltY?11r11ei1t&l/Site �l9SS591i1av111 <br /> A11lft7rnlation to the SAN JC.)A I)tN COL)NItY LNViRONtv4ENTAL 14BA:LTt1 DEPARTMENT as Soon its it is: aitailable aiid at the saitye tirire it 'rs <br /> provWed to me or my representative, <br /> JOA <br /> TYPE op Sumet RMESTED, UST Clo6uri� in Place <br /> - - - <br /> VP <br /> AmIoI <br /> GOrarheNTs; <br /> SqN MAR 16 ?021 <br /> Jp <br /> t HE��0/y/MFNp�NTY <br /> A <br /> ACGE€'TPC113Y, /l f>_ t:rliPLioYE ; : I)ATEP / (P <br /> T <br /> ASSIGNED Y011 � � v , EMPLOYEE; DAYI:: 3z / - <br /> L.� <br /> [tate Service 0omplet€t if aiready Born oted)% SERWOF Co[iE; I' l Ei2 <br /> Fee Amount' IOU Amount Pat � � Payment Date 30. Z <br /> - - - - - <br /> Payment Type J� Invoice # Check # LILY 44S Recoviod By< <br /> I I-17_48-D2-U25 SR FORM (Golden Rod) <br /> REVISED 11117/2003 <br />