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SAN JOAQUIN COUNTY ENVIRONMENTAL IFTEALTN. DEPARTMENT <br />SERVICE REQUEST , <br />SERVICE RE VEST # r (6 FACILITY ID # — <br />els Type Buns or Pro rty <br /> imarTtArtyvA____ <br />6 <br />, V..., <br />OVI/NEK/ OPERATOR <br /> <br />CHECK If 131LbiNG ADDRESS <br />I k(fAvqftk". elr6tet .A4 "r-S: <br />7 <br />FAciuTY NAME f% <br />g 1.0 StrNumb tion D <br />LOtilie S trAff4 nft/ 144( <br />at Na <br />5'11,i ADDRESS <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />stretatliarno Soak Numb'''. <br /> <br />STATE ZIP <br />Cirr <br /> <br />LAND USE APPLICATION* <br />Es. BO$ 01$TRICT <br />CONTRACTOR / SERVICE REQUESTOR i___ 1 — <br />REQUESTOR jet( 8DAr(4, i CHECK If laiuxig ADDRESS <br />711 _ <br />BUSINESS NAME 9 1 <br />S <br /> --- <br />PHONE # EXT. <br />L <br />4X1 _ 1 . <br />L-Spi.q 1 001 i / <br />HOM0 <br />1 rr7 ( b ) ._4 ,/-4,/,2 7 7 I <br />E r,y1AILINc ADDRASS <br />la ) 3 _j_aq_.. <br />CITY fri STATE 4.,_ ZIP <br />— 11404,[11, i— I r--- <br />BILLING ACKNOWLEDGMENT: I the undersigned property or business owner, operator or authorized agent of saline, <br />acknowledge that all site and/or project specific ENVIRONMENTAL FEALTI1 DEPARTMENT hourly charges ass'ociated 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 bc performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Orthmance Codes, Standards, S'I' A: ' 1C1 FEDERAL laws. i <br />4.3 —of <br />13(4'17(7 <br />PHONE 2 <br />( <br />EYT. APN <br />2-61 /7 C.) -0 <br />LOCATION CODE <br />Payment Type ft. <br /> <br />Invoice # <br /> <br />Fee Amount: 14 24 0 .0-D <br />APPLICANT'S SIGNATURE: <br />pRopeary I titisiNitss OWNER 0 <br />DATE: <br />OPERATOR/ MANAGKR gfr OTHER AUTHoTuzzo ALANT 0 <br />IPPPLIciiNT is not the 1314.M0 PARTY, proof of authorization to sign is required Title <br />AVT.IFIORIZATION TO fteLEASE INPORMATION: When applicable, 1, the owner or operator of the property located ad the <br />above site address, hereby authorize the release of any and all results, zeotechnical data and/or environmental/site assessnlient <br />information to the SAN JOAQUiN COUNTY ENVIRONMENTAL T-TEA1,,TI-1 DEPARTMENT as soon as it is available and at the same time k,r is <br />40 'i311'11\t-F\111:7 <br />provided to me Or my representallve. <br />TYPE OF SnVtCE REQUESTED: R_ 4-€ 64_0 <br />CommErrs: <br />grE it k <br />JUN 2 3 200 <br />tor.,,Ot e <br />64 <br />P`I ',/iP,C1NNliTk T „l44-\rle"C'EP <br /> <br />EMPLOYEE #: 1. <br />ASSIGNED TO: TiOefAEL-.:z,,. EMPLOYEE #:ra&24002: 3 <br />- P IE: 5 r 3 ixyi2__ Mate Service CO m mpieted (if already ccclotod): SE <br />ict. c <br />Amount Paid Payment Date U,J 2. II/ 0 9 <br />ACCEPTED eY: 0 Li. ‘9€- <br />Gieeek Received By: <br />k(4.1iiss SR FORM FORM (Golden Rod) EI-ID 48.02-025 <br />REVISED 11/17/2003