Laserfiche WebLink
03107f2005 16:17 2094663433 FIFTH FLOOR PAGE 09 <br /> oar.,trA.t, -'J- u 4_-OLIN-1-Y iso(-IRONMENTALkM.A►L,TOEFARTM-ENT <br /> SERVICE REST <br /> Type of Business or Property FACILrTY tD# SERVICE REQUEST# <br /> S-eoQ PSS®C� <br /> 65- ' -7 X200 y14 q(a <br /> OWNER/OPERATOR <br /> VT CnacK if BtLLiNG ADDR $ <br /> Fncainr <br /> AgaFMM <br /> p � /� <br /> 39L-+() screct Number Dtreaffia� 1 V 8�'�N Namei� �` 'q�3�b <br /> HOME or MWuG AnDRESS (it olff rent from Site Address) `�j <br /> Street Number H <br /> CITY STATE zip <br /> PHONEM APN# LAND USE APPUCATION 0 <br /> (D-OR) moo© X13. moo 0� <br /> t3cr. BOB CN5'rRIGT WCAMN CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REt�E$TOR <br /> CHECK if J3iLuNs AnnnessO <br /> Busymas NAME ' PHONES * r <br /> HomE or MmuNG ADQRESS,� Fax# <br /> 3WQ -SLiols <br /> CrtTY �'� STarc ZIP <br /> t ll, <br /> RlZ'LIi C- AGKN0VnXDGFMNT: k the undersigned prop wty or busium owner, operator cr authorised.agent of same, <br /> acknowledge that all site andlor project specific F-WRONMENTAL REAL7N DPFARTmENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this€arm. <br /> I also certify that I have prepared this application and%at the work to be performed:will be dome in accordance with all SAN JDAQufN <br /> COUNTY Ordinance Codes,Srando ds A and FE' AA aws. <br /> APPY..ICANTIS SIGNATUREr -7DATE: � Q� <br /> PROPERTY/BUMNESs OWNCRP� OPERATOR l MANAGER Q OTHrRAvTxomzeuAc=0 <br /> IfAPPLIC4NT is not the BH.LJNG PA=proofaf authorkation to sign is required Title <br /> AUTIROR17ATION TO REBASE INFOR ATIOPic When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the zelease of any and all results, geotechnical data and/or envirorow tallsite assessment <br /> inf0r=tlon to the SAN JOAQUIN COUNTY ENVU;k 7NMENTAL HEALTH DEPARTMENT a5 soon as it isova V. 1�ze same time it is <br /> provided to me or my representative. 9 <br /> TYPE oF-SERmE REQUESTED: <br /> ' 6 COUNN <br /> 3OPQUM <br /> lN PL <br /> i%�L; ° Errf - <br /> ACCEPTED By., PLOvne M. DATE: f — <br /> A=GNEa To. C EMPLoym#: DATE_ <br /> Date Service Complet (if aitemcly completed): SEIMCE CODE: PIE: <br /> Fee Amount: Amount Paid; :X-747. D c0 Payment Date 3 6 b S <br /> Payment Type ✓ Ittucllce# trheck# I b3 Received By: <br /> EHD 48-02-0*-5 SR FORM(Golden Ft <br /> REVISED 11/17x"3 <br />