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SAN JOAQVIN COUNTY ENVIRONMENTAL 11EAIJvII DEPARTMENT <br />S1?I(vit E it114VUES'I' <br />Type of Business or Property <br />BUSINESS NAME n \ , <br />f �Y IST1c \v 5i7 <br />FACILITY ID 0 <br />SERVICE REQUEST Ill <br />B 0C� Ayv_ <br />CITY <br />I v eE' Gut k STATE � z,P `i s <br />OWNER / OPERATOR <br />Cleat tf BILUNa ADDRESS9 <br />SAN ✓O <br />&N AQUI <br />H�Cly p <br />FACILITY NAME <br />PORT <br />SITE ADDRESS ' CJ 7.i �- <br />2 h <br />} <br />EMPLOYEE #: n <br />DATE, <br />Z b <br />Street Number <br />Ditecm <br />DATE L/ a I to I <br />strw Now <br />Zip Code <br />HOME or MAILING ADDRESS (if Dtfforent from <br />Sits Address) <br />Fee Amount: r J! a Amount Paid <br />/5'1� Payment Dato <br />/.1. <br />Payment Type <br />Invoice # <br />INu <br />Received By: wv <br />CITY <br />STATE ZIP <br />PNDNE Irl UT. <br />APN 0 <br />LAND USE APPLICATION 0 <br />(2ol) +01-';�7GjD <br />11tow 02 E*T• <br />l ) <br />BIDS DISTRICT LOCATION CODE <br />CONTRACTOR / SCRVICC RCQUCSTUR <br />REQUES7OR CX NG ❑ <br />And��cW 5U CHEIf BIWADDRESS <br />��Lt�� <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, <br />BUSINESS NAME n \ , <br />f �Y IST1c \v 5i7 <br />PHONE ExT• <br />ill `�a('� S 790 <br />HoME or MAILING ADDRESS <br />2Ds�I k�t��h-� Ct-• <br />FAx i <br />( ) <br />CITY <br />I v eE' Gut k STATE � z,P `i s <br />operator or authorized agent of same, <br />acknowledge t11 It all site and/or proj(xt specific Il9vtttoNMt NIn1I lltnl. I UI:PAttlMI A sourly charges assoc ated with this project <br />or activity will be billed to me or my business as identified on this form. <br />1 also certify that I II:Ivc prepared Wis application and <br />that lite work to be perfonuLtil will be dont in accordance with all SAN JonQuw <br />CotrrriY Urdinarrce Codes, Standards n� ti and PFt�P L. v . <br />APPLICANT'S SIGNATIJIM: DAre: <br />I'RorEmy/QI;sIrnESS OWNERN OPERATOR/MANAGER ❑ Ornmia Ain iiowzED AG"r❑ <br />If APP/JC.L87 is 1101 the /11/JJAN(i /'ARTY, proof of authorization tosign is required Ti it e <br />AUTHORIZATION TO Ri:LF,AS[: INFORMATION: When applicable, I, the owner Or operator of the property located at the <br />above site address, hereby authorize tsc rclydsc of arty and all results, gcotcchnictl data and/or L�Jlviro <br />rmlentaUsite asscsslnent <br />Infonnation to UIC SAN JOAQUIN COUNTY I:NVIRONMEKI'Al. I lEALs 1 DLPARTMINt :LS soon as it N available and at the sanic��� s <br />provided to me or my representative. <br />Ova <br />TYPE OF SERVICE REQUESTED: CO <br />eo <br />ljN7y <br />t <br />'"�` <br />COYMEWS: <br />el fav `j <br />SAN ✓O <br />&N AQUI <br />H�Cly p <br />PORT <br />ACCEPTED BY: t NJ tjrI4 <br />EMPLOYEE #: n <br />DATE, <br />ASSIGNED TO: <br />EMPLOYEE P G <br />DATE L/ a I to I <br />Date Sorvlco Completed (If already completed): <br />SERVICE CODE: <br />IDG' <br />P 1 E: N 1 O i <br />Fee Amount: r J! a Amount Paid <br />/5'1� Payment Dato <br />/.1. <br />Payment Type <br />Invoice # <br />Check # <br />Received By: wv <br />EHD 411-02-025 ON `7) " • 12`( t �✓ �(� SR FORM (Golden Rod) <br />REVISED 1t/17/2003 v '�"j' <br />C <br />FNT <br />