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SAN JOAQUIN COUNTY ENVIRONMENTAL DEALT!' DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Re Sri iii) k/i7Q .-1— <br />OWNER! OPERATOR <br />0/9 L :J i A) Op,/t. Is <br />FACILITY ID # <br />{ )1-- A o 0 c <br />SERVICE REQUEST M <br />SRCbCDS ii--z ,-( <br />CHECK II <br />iiira-- <br />BILLING ADDRESS MI <br />FaCurr NAME ,.,— <br />I AA; 00-tit. I (lit( LL :17- 10 Of 4,PJ (.,t1 i ,I fLi <br />SITE ADDRESS <br />sq..,Numbsr cireccon ea sic 6 Sava POMO <br />I PO A) (et <br />CRY <br />qS-34 Ile ;oils <br />HOME Of MAILING ADDRESS (If Different from Site Address) <br />StrPel Name <br />CITY STATE ZIP <br />PHONE ffl Ex!, <br />a01)6q0-3/s- q <br />APN II LAND USE APPLICATION R <br />PHONES2 En. <br />( 24,',/ ) 6 q o - 3/s9? <br />1305 DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQI ESTOR <br />REQUESTOR <br />/A) Of/'t ICA Ug- <br />Crecx ir BILLING ADPNES)11 <br />BUSINESS NAME, <br />I ft fV1 0i)CA i C/(4 I c(- .1.7i00/4-x) (...e.i. 1 .i 'or:: <br />PHONE # <br />1 2.7) Ge/r) <br />E',r <br />HONE Or MAILING ADDRESS <br />/ 4 02— /-A) 6.131-0A)Y All ...Stt ,I) <br />Fax 0 <br />( I <br />CITY RIPON/ STATE 6., ZIP 9, c-3( <br /> 8 <br />BILLING ACKNOWLEDGEMENT: I the undersigned propert, or business owner, operator or authorized agent of sank, <br />acknowledge that all site and/or pmject specific ENVIRONNIENTM, I lifrAit`rstmr hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify. that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAO11N <br />C4 II N I 5 Ordinance Codes„Veindards. Si ME and FliDifi Ai laws. <br />DATE: 0 z fiy Zatki <br />NH*. r / •SINE :0%1 ,<0 011HATOM MANAGVN 0 01 I IF it Al' 1110RIZM ACESI 0 <br />in PITA V1 is nut the RP I1\c; I'. NO F. rupq of outhurizidiun to sign is required Tish <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I the (toner or operator of the propen) located at the <br />;those site address. hereby authorize the release of any and all results. geotechnical data and/or environmental/site assessment <br />information to the SAN latol TIN COI 7‘.11' EvakoNmEALki.Hi ALTH 131,PAICIAItNI as soon as it is available and at the same time it is <br />pros Wed to me or my representative. <br />TYPE OF SERVICE REQUESTED: (%„,s,,e___e_ouiti,ys-tt.t_r <br />COMMENTS: <br />. ., •(-1.1.........t.A. <br />ACCEPTED By: EMPLOYEES: gy. g 2 DAyE: 2 ) lc / <br />ASSIGNED TO: EMPLOYEE 0: DATE: 2_ i ( L2— 1 2.1 <br />Date Service Comple (if already completed . SERVICE CODE. 0 Li P 1 E. izp./.2 02) <br />By: 6,41b— <br />Fee Amount: c_ 4 2_ Amount Paikiir /0. 00 Payment Date V <br />Receiv Payment Type i Set— Invoice # Check 0 174,52 2 3/E <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 111172003 <br />(6)+N(vv <br />1 e,-4-- <br /> <br />APPL1CANrs SIGNATURE: rt. ' <br />FKo,5210q,-(1-1