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S E P L� �tTm 'f3L1NTYLt1NICIENT\L I $A'LTH�IElP kRTMPNT <br /> SERVICE REQUEST s�tvlcelzEouEsr� <br /> FACILIT'i'ID# <br /> Type of Busindss bVIDIT1010WENTAL <br /> , <br /> HEALTH DER,*ITMENT 3.O <br /> OWNER I OPERAt'ORCHECK II EIL INO D $❑, <br /> FACILITY NAME (✓� �•� ��. .. /' '• /J,r ( Q /'�,/ <br /> SITE ADDRESS <br /> HOME or MAILING ADDRES!3 (ItOtfferantfrolrt9ite pldtlntssY s a <br /> Snyel Na er zip <br /> crry <br /> Ezr. -APN#.'. <br /> • LANOUSE APPLICATION# <br /> PHONE#1 . <br /> ( I LoCA'O9f! ODE <br /> . 'SC3[7i5iRICT 3 <br /> PHONE.iF2 ' <br /> I I GO1 AG UI QUESIT I2. <br /> REGIUESTOR 'CHECK if Br INGA oRE <br /> ENSINEss NAME i 1.0 ' <br /> 72 <br /> HOMED MAILINIJIki5ssrl ! .) <br /> STATE z�r <br /> CITY <br /> BILLING .\ KNOWIi 1)GE1 :'I; the uhdEtsfgaed pro�ett$ or bdsittx4s oWt erD 6pertitor.or authorized agent of name,, <br /> auknnwiedgc that all s!te,9htL(or pro,,)ect.spect$o'S Mp-brNmt,-NfAL It;ALTN�7.9'0?r'NT hourfy,cliatgesassociated with this project <br /> Or activity will be billed am or my'I'itf9Uiet'd as tdefififibd:an tFtia form <br /> ! also ecrtliy that 1 have prepared ttaS.app!iO4ttoh add'tlYat tha,woCk taba potf2r�tivlill be done in accordance with all S."4.tuA,Cnsrl <br /> t::OUNry(J+'rlinrrnee(:odes,Slattdardy�TA't'g and'FEbgitAl.laws;. <br /> APP1.:ICAN'1"S g16N.S7'URC <br /> DA5 E :aA <br /> 7 uovell lV i 111I11NES8 OWN%Kr ClreitATOIR l ItLOAGtR D O7t115NKV'thl0tlt7ab't1.rrRN7 ' rtrfe Y <br /> proof uuthdrt attan Hf A4'require <br /> #J PPLIGINT is nnr thcAUiLJ d . P f a l <br /> AI!THOR ZA: N.... Bjm I O v Whcit appliD681e,�;t$e dwneT or operator of[he property located at the <br /> >�e site address, heteby attthorzc.ttterelcase of aay and'all tesuyts, <br /> geVafdchnical dam .andloi environmental/site amassment <br /> 41�111nation to I:Ite SAN.fOArJUIN COUNTY l'NVIROiJI'AFN7kt:HFilT.TA DFFA'li'IT1Ect'f`0.a 6nDn sq 14 i5 available and at the same tiR!e it is <br /> MF <br /> to me or my representative. . . —'-- <br /> F SF,RvicE REQUESTED: Pcc <br /> OOL S/f}. :. '4,1 R�$/-4 G/�LC L ��' G'f'f �-- . <br /> MM� rC V PAYME T <br /> SO�Y A <br /> RECEIV D <br /> f <br /> SEP 18 009 <br /> SAN JOAQUIN(IOUNTY <br /> ENYIRONME AL <br /> ENT <br /> Arr.�PTs Ear• O L C VEt IO-/E - .. �f1ei 7t.Eh#i .p32/ ^aT.: (F 0 <br /> ASSICNED TO: �y�Q)Q-24t <br /> EaiI+LOYEE#: G 213 DATE ^. !P1 0. <br /> ..Date Sarri:? Comp!e'r`d (it already Co'wlofod)1,. .. <br /> SatsvcEcobe: <br /> Amount Paitl . .Payment,0alfe p <br /> Fee Amount. �Z3,0 ,d"7 ., eceivod!sy: <br /> Chaok#('. '' O <br /> rf aYment Type �.�t/ � . � Invoice# � <br /> l/p7©� GLp?/Q �DKD Onlmm Rod) <br /> EHIJ 48-02.025 SR FORM( <br /> REVISED 11/17/2003 ., ,. <br />