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c <br /> (�=, CLar K CIP 1: ' <br /> r =4, )T <br /> SERVICE REat1EST •(SERVR£Q) Revised 5/13/43 <br /> FACILITY ID t RECORD !o 0 o* - ' F=" 2: 9BtlllNt: aARYY Y / <br /> j- <br /> 15R*oo?a 90 <br /> FACILITY MANE - C. 415 JC.T <br /> SITE ADDRESS �-� 3 0. W. Gl/�9�'�'6'7a�✓ sr <br /> CITY '/ �`-'�A/ a 21P <br /> OtAn,XpERATOR ROA--r t67ILLING PAM Y / N <br /> C�RG/CIL E•ts ��S ZOO Pwm si 7O'7)� ogle <br /> i . <br /> CITY aTATE C- zip <br /> AN f 1 - O3Q� Census ---•---^ Bas Dist 7location Code city Code -•--•• <br /> COMYRACTOR and/or <br /> 6ILttNc DARTY <br /> SERVICE REOVESTOR 7/ ��l/�' I N <br /> ✓ MAILING ADDRESS Y%/✓ //l�//fI����7 5je/ALT pt./ rAK R (��) g'-'3- 31177 <br /> CITY _�- G+ /Gly STATE C`T ZIP <br /> BILLING ACKNOVLEDGEMENi: i, a Undersigned owner, operator or agent of some. seknowledge that all site aexi/or project specitle <br /> PNS/ERD hourly charges assoeigted with this facility or activity will be bitted to the party Identified as the BILLING DARTY an <br /> page I of this form. <br /> 1 also certify that I havered this application and that the work to be performed Witt he dant in N! all WJDADtlIN cmwrY Ordinance Code and Standards. Stat&old Federal lard. � �� <br /> Y APPLICANTOS SIGNATURE <br /> Data: <br /> AUT"ORIZATiON To REII'.ABE INFOi:IU� ATION: in addition to the above, Nqn Rpptiesble. 1, the owner, operator or amt of same. of <br /> the property located at the aLm site address hereby authorite the release of arse and sit results. WtOtechniesl data and/or <br /> envirormentst/slte assesowrit Iinformation to SAN JOAOUIN COUNTY PUBLIC REALTB SERVICES ENVIRONKMAL REALTN DIVISION as soon as <br /> it Is available and at the seas time it is provided to we or ay representative. <br /> Nature of Sm►ice Request: service Code <br /> Assigned to Employ 0 <br /> Date Service Casptated / � Further Action Required O / N PROGRA1t ELEiIENT <br /> 29, So <br /> Fee Avant Amount Paid Date of Payment Payment Yype Receipt E Chockit Rem By <br /> -if23 .00 3� 1-�-9 ✓ 61 to 42 <br /> RENS J��� .r.../ ./..._ _.._/ , r uNtI Clic ._...J..,J._. <br /> 2 'd Ve:60 96ZVO/10 W08:1 <br />