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X14-09-22 15:19 ■ to C`1 Visalia Sales 15597320817 >> ZR 4 &VED USAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SEP 2 2 2014 (C�1J2 do, SERVICE REQUEST ENVIRONMENTq LHEAi 14 Type of Business orPropertyFACILITY CHECK Ir)�ILLING ADORC38 / vl'1 �{'IIJ' � ID 0 SER ES ACCEPTED BY: PHONE# NOME Or MAILING ADDRESS 2C 1�CITY DATE: FAX 0 64 STATE ZIP 93 3 Com' C Date Selvico Comploted (If vlroady comploted): SERVICE CODE: OWNER 1 PERA'rOR P I E: , 13 -� 4ICT ,-I 2 G- c!�� u r.n ✓✓i C 1 CMBCK If t;I1LLIN0 ApORct�s FA ILITY AME r4IL ` .i C/ /�Y�•1�(.I �� Lel �.,5 Chock tt SITE ADESS.y%�a� � 74- 4t"Af I n � I -W 14rnCity• HOME or MAILING ADDRESS (If Dlfforont from Slto Addrosa) r Z- t" ,: 5 e.r.t NumWr RM+nNikint CITY TA ZIP STAT, PHONE #i EXT APNIS LAND USE APPLICATION tt PHONE 02 Cet BOS DISTRICTLOCATION CODE (? ) 923 — 9753 CONTRACTOR / SERVICE REQUESTOR RECUESTOR - CHECK Ir)�ILLING ADORC38 / vl'1 �{'IIJ' � COMMENTS: - �r. r: � c � t�.'� C� t f� � r\ # l•. J C L:� ,�;� G.,, �; �, -t�; , �, � � �� 7—q i y BUSINESS NAME / � ACCEPTED BY: PHONE# NOME Or MAILING ADDRESS 2C 1�CITY DATE: FAX 0 STATE ZIP 93 3 Com' C Date Selvico Comploted (If vlroady comploted): FIILLtNG A(' "NOWt li1l__F NT: 1, the undersigned property or busine4s owner, operator or authorized agent of same, acknowledge that rill site and/or project specific ENVIRONMENTA1. HI:AI 'I'll DF.PAR1-Mt:N'f hourly charges associated with this project or activity will be billed to me or my business as identified on this form, 1 also certify that I have prepared this application and thut the work to be performed will be done in accordance with all SAN JOAQUIN Coutr 11' Orefinance (.odes. Stundur&y. STA th and FLI)ERAI. laws, APPLICANT'S SIGNATURE: '.%� DATE: PROPERIA/ fit �IN�:Hs C>wnE11❑ OPERATOR / NIANACER T3d OTHER AUTI10uIZED,\CRirr ❑ Il:Irrcrc,l.+r i,v nor rhtr Ialr.l.l,>,c P Irl'/), proof of aurhoriturion ru.vign Lv required Title A )THORIZATION Tg RELEASE INFORMATION: When applicable. I. the owner or operator of the property located at the above site address. hereby authorize the release of any and all results. gcorcchnlcal data and/or environmcrltal/site assessment information to the SAN JOAQUIN COUN-IY ENVIRONMEN'rAI, 1-11FAI_11l DEPARTMENT as soon as it is available and at the same time it is nrnvirlyd In me or my renresentative, TYPE OF SERVICE REOuESTED: COMMENTS: - �r. r: � c � t�.'� C� t f� � r\ # l•. J C L:� ,�;� G.,, �; �, -t�; , �, � � �� 7—q i y �r�s-� 1,�t..� � ACCEPTED BY: EMPLOYEE M DATE: ASSIGNED TO: EMPLOYEE 9. DATE: Date Selvico Comploted (If vlroady comploted): SERVICE CODE: P I E: L=eo Amount: Amount Paid Payment Date Paymont Typo Involce tt Chock tt ROCOIVod By: EHD 48-02.025 SR FORM (Golden Rod) REVISED 11/17/2003 Received Time Sep,22, 2014 3:24PM No,7116