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SAN JOAQUIN COUNTY ENS'IRON\!ENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY In# SERVICE REQUEST# <br /> OWNER I OPERATOR An S -50&j% ,(n WK V I `ICP Cir Ed <br /> J KV(r 11.ftHEGK Ir 81LLINn AnDRF55 <br /> FACILITY NAME <br /> SITEADDRESS 3314 rCT� �1��"e "s"eS�O&Aron Q520y <br /> Street Numher Dnm ion Street Name ag2-7707 <br /> / c 'Tr. 2i CO6L' <br /> Hoor MAILING ADDRESS (If Different from Site Address) 2,",07' 7rGnSwD <br /> orld . <br /> I Sveel Numbtt <br /> CITY C toe i J r n STATE /1^ ZIP ns�i <br /> PHONE#I `JL I�TIJ fir' APN# LAND USE—AP*7P'UGATION# 7 <br /> PHO14E#2 EST BOS DISTRICT LOCATION CODE <br /> 1791 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR / 'ar`ne � oumhe-� <br /> l/.�. ^ CHECK If BILLING ADDRESS <br /> BUSINESS NAME S` � -1 Lkin �O un l t I'�o Oi C PNGNE r/r V —qv?-Ext. <br /> HOME Or MAILING ADDRESS 270`/ '1 MrIS . rTO/- Id ll r] (' (A'#� `j /f'Wj_9_ �wG 1 <br /> CITY _yti ��/ r( r Irl .7V�/ STATE )1 `T SP"P65213 6 5 213 <br /> BILLING ACKNONVLEDGEIIIENT: 1, the undemguel Property ur business anner, operdtnr or aulhorited agent of same, <br /> acknoxvledgc that all site and'or project specific ENYIRO\ML•-NI AL IJLAL ill DLI':11t I\,IL.I hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this firm. <br /> I also certify that I have prepared[his application and that the work to be pelfommd will be done in accordance with all S:\N JOAQU[N <br /> COLIN Il'Ordinance Crxles,Slevtdar(nak <br /> 11 and FEDERAL hoVS, �J <br /> APPLICANT'S SIGNATURE: _ gt1r DATE: <br /> PROPERWI BLSI.YESSOAGCER❑ 0PE1LSTnRISJ.LN.\GER13 OTIIL At'TItGRI7TIrAGE�7 1�1(� 1•I-l�n .)I��Q�.(S� <br /> I(AYNLlC:a:\7istrot the BLLLl.\'GI)fR7),proof ofauthorization ln.signisrequired <br /> Title <br /> AUTHORIZATION TO REI.F-ASF INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> rshoVe site address, hereby authorize the relemcc of any and all results. geotechnical data and/or environnlentallsite assessuicat <br /> information to the SAN JOAQI IN COCNry Ii\'\'IRONAII'.NIAI.I lL\I.TI[pfP.\RTMG\'f:w Soon as it is available and al the same time it is <br /> provided to me or my reprL:scnndive. /f <br /> TYPE OF SERVICE REQUESTED: t'o 5-Tc C-C S C�.."C_ RECENED <br /> CONMENTS: AUG 0 3 2021 <br /> SPN...outs Lo OItV <br /> ENVIRONMEN <br /> HEALTH OEPPRTMENt <br /> ACCEPTED BY: ����„�S Lq EMPLOYEE <br /> l <br /> ASSIGNEDTO: - Olrya 5 EMPLOYEE#: DATE: ��- <br /> Date Service Completed (if already completed): SERVICE CODE: ? Pi E:11-4112 <br /> Fee Amount: I STS Amount Paid Payment Date <br /> Payment Type Involce# Check# �py . 'J� Received By: v1 <br /> EHD 48-02025 SR FORM(Golden Rod) <br /> REVISED 11/17,'2003 <br />