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vJ1le$/2]84 15: e9 2854683433 FIFTH FLOCK PAGE92 <br /> SAIN JOAQ T-"N COUNTY ENVIRONMENTAL HEALTR DEPART)tiM T <br /> �� • SERVICE REQUEST <br /> Type of Business ar R-cperty FACILITY ID f SERtfCE REQUES # <br /> Tr�'Oo3� <br /> CHECK tf BILUNG AOOR55S <br /> FACILITY NAME <br /> SITEAC7RE5Ss zus <br /> "] <br /> `66 r Sir" *lumber Oimwton -city Zig Code <br /> PONIS 0r MAiUNG AJDREBS (I€Different from Site Address) <br /> chr L.A.PERKS Kelly York <br /> PLUMBING AND-[EATING <br /> PHONE 41 exs. APN# INC, E <br /> CONSTRUCTION &SERVICE <br /> P40NE#2 e" PETROLEUM TANKS&PIPING SPECIALIST ooe <br /> ( I Nevada Lic.812556A•Oregcn Lic.8147496 <br /> CUN'TRACTQ. Bus:(775)358-44o3 CA Lic,8678948 525 Spice Island Dr.,BF <br /> f Fax:(775)358-4411 Sparks,Nevada 89431 <br /> ��f RE4UEST0li �� Email:kelly®perksplumbing.sam rt=s5 L! <br /> _ trr. <br /> $U51NES3 NAMEP( C T 1 f77s c3 '^ '/q0-'3' <br /> 1 <br /> L HOME Or MAIL!Nc ADDRESS � '7 <br /> 2 -Sl� r• I ( i^► 3Sg—YY► I <br /> c:Tv �)P` --r SrATe �)� ZtP <br /> iLLZNG ACK-"i0)rVLEDGE v1Eti'T: L the umdersigncd property or business owner, Operator or authorized agent of same, <br /> a:k3ohidd;e rl:aC all site ancJ°oz protect spevizic ENVIRONIvICN'7AL HFaI,T.-t DEPAR",VENT hourly caer;cs associated wiLl this projector <br /> :ctiviry will be billed tome or my business as idemilzed onthis fotrm <br /> also certify tlsa;I:'save prepared this application acd that t!:e work to be perforMet,' w li be doss is accordance with all SAN Jo,�t t lv <br /> 'r:?LN:Y Ordinance Cods•,Srandardi,STAic ndr'E laws. <br /> APPLICA-N-T'S SIGN-A.TURF,: D.aTE: r <br /> PxopER7y/BusiNzss 0w'NFsL1j OPFxA-roR,'' NAC.ER ❑ OTHEIAUTSOAIZEOAGF-NrrS l <br /> if.'?p,.t..tlr'7,L,:90r t)'1e 3jLLjw(-,P,4R77'proof of uuthoricadan to si;v is required Time <br /> ATJTHORIZATTI)N 70 RELEASE-rNx OR; ATIOiti: When.applicable, I, the owner or operator of the property Iocated at t::e <br /> above site address, tere>3y 3,Uthari�e --he _e'ease of any anti all results, geote,hrical data and/or =vi:owncntal'site assessrren: <br /> infer:^ rob:0 Z,%e S,ax JcaQvrli.CvU`riY x vV1Rtilti iE�7AC HSI:Y L' .�. naE-r as sroa as .t is aL'31iaa':e znd a:'I a saw a tir:c it is <br /> pravi&d`.c me or mf n:prescntative, <br /> Tyn of SERVICE€iEQUESrEC: u 5 <br /> ACCFP"ED$ Ey.PLOYEL _ DA`c: /' <br /> ASSIGNED TD: EMp,-QYEE#' DATE: <br /> Date Service Completed (it already completes!): $ERVICECJCE PI c: LIS <br /> Fee Amount- �� � Arnvunt Paid, � �j�- � Payment Date. L �(� �t{ <br /> Payment Type ✓ Invoice# Check O(o 5 Received By: <br /> pAYMEN I <br /> Wcasn Rod) <br /> REVISFC 11/17=01 <br /> (,moi 2 <br /> '( . - - JAN 2 6 2004 <br /> JOAQU'N COUNTY <br /> SA ENVIRONMENTAL <br /> LTIi DEPARTMEW <br />