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SAN JOAQUIN COUNTY ENVIRONMENTAL,RRALTII DRPAItT11/1iNT <br /> SERVICE REQUI'S-1. <br /> Type of Bualne ss or Plopaly FACILITY ID/ SERVICE REQUEST H <br /> Snrl `ICL hU _ LFA WZb-7SC 5ROO859 <br /> U8 <br /> R <br /> OWNEI OrranTQn /� � � � � — <br /> l/ VCk <br /> Cra cn if Bnitno Anoerss❑ <br /> FACIVII,NAML 1�N�A <br /> SITE ADDRESS 1 61nelI -1 ( y �1` (..0 I�fY➢ ��. �+ MJf 1 _'C a ' <br /> ll1umlmr In�[xon �/L Slrerl xym <br /> NOME Df NAIDNG DDF1[4S Dwllrerenl from Site Address) r <br /> M..reAeOn rr Name <br /> CITY EI L KYv ^ E" STATE CA rzip <br /> qS2-(-)5()5 <br /> PHONE APN0 LAND USE APPLICATION# <br /> I zoq) LI 30- 4 <br /> PHONE 42 En. BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR I'SERVICE REQUESTOR <br /> REQUESTOR 1/�, <br /> ,`\(', rCHECK If 9nLIHGAO0RE55 <br /> BUSINESS NAME \` ,vt U(/T I 1 I � 2�P76 _ 5'0' <br /> HOME or MAILING ADDRESS , I ,/'f, �C� ��.T lMill <br /> CITY S 1^ rA lAI LU^ STATE CA ZIP LIS <br /> Z/\ <br /> BI1.IANG ACKNOWLEDGEMENT' 1, IIIc undcrsigHed properly or business mvner,Operator Or authorized agent of Saint. <br /> acknowledge that nil site an(Vor Project SpeCil ie ENVIRONMENTAL.I ILALTH DRI'AMIMLN'r hourly charges associated with this project <br /> or activity will be billed to me or ray business m identified ml this fans. <br /> I also certify that I have Prepared this appdicaliou and dial firework lu be performed will be dune in accurdmlce with all SAN JOAOUIN <br /> COUNTY Ordinance Cates,Sfnndr rds,S" 'Ili and IFEDIAIAL IawS. <br /> AIIPIACANT'S SICNr1'1'Uf;f•::\ ,,Q�Q/1 �,�(/'� C.DaTE: I o l20 /a 2- <br /> PROPF.It'TV I DUSIs sOnxnlV1J 'eOrEl(A'I(IIr 1 IN' NEER ❑ 011 MIT Ain NttlZim AOr:Yr❑ <br /> It 01-LiCANT is ear The IIII.1.hY(1P.INN%prnnfnfnothorization rO sign is required Tirre <br /> AUTHORIZATION TO RRI.P.ASE INPORMA'I'I ON:When applicable,1,fire owner or operalI,r mf the Properly loc;ded al the <br /> above Site address, hereby authorize the release Of any Hud all results, geute:hnicld dila and/or etivianmme Ndlaile HISVII <br /> iml'millation m the SAN JOAQUIN COUNTY ENVIRUNMLNIAT le:\Lill DI:rARIMI.W G`sOOR aS it IS available 01111 at the Seale timkf�/��y�.MENT <br /> provided IO m <br /> me ur y repruscnlalive. q rt`yEIVED <br /> TYPE OF SERVICE REQUESTED: 1 DIV 3 120 <br /> COMMENTS: �.vrl. <br /> SANJO OUINCOUNTY <br /> ENVI ONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: I �� EMPLOYEEM DATE: — — <br /> ASSIGNED= EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 061PIE:, <br /> Fee Amount: 5 — Amount Paid -- Payment Date 3/ L <br /> Payment Type VLS Invoice# PLO,#'/S�p;�.2 Received By: <br /> EHD 48-02425 �O/ � Z�� SR FORM(Goldon Hod) <br /> REVISED 111172007 111 <br /> , <br />