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ERVICE �2.>��'Q U E"S"i <br />1 Me of Business or Property FACILITY ID it SERVICE REQUEST # <br />CHECK If E3ILLING ADDRESS ❑ <br />BUSINESS NAME lL LoC�� <br />OWNER/ OPERATOR <br />PHotlE It FIT,1 <br />(2vg) 3�� 'M& <br />GQ 1 '\ Mq !Df: M/g e Q CHECK If <br />N <br />BILLMG ADDRESS <br />FACILITY NAME <br />CITY L 07j)( <br />SITE ADDRESS 'r J �� Irce! Number <br />T t <br />Lo -b 1 <br />EMPLOYEE It: � <br />(zlo <br />ASSIGNED TO: <br />Dlrecllnn Slbcul Name <br />EMPLOYEE it: S*413 <br />DATE: / G <br />CoUc <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />_CIIY <br />_L1 <br />I P 1 E: �� C <br />1 <br />Street NumberT <br />Street Name <br />���� <br />CITY• <br />_ <br />STATE Zlrr, <br />PHONE tt I EXT. <br />f ) <br />ApN i! <br />LAND USE Ar,PucnrioN /t <br />PHONE iiZ Exr. <br />t i <br />— — <br />00S DISTRICT I <br />—`--- <br />LOCATION CODE <br />CONTRACTOR / tSERVIC>r.+, REQUf,fiTOR <br />R;EQUESTOR <br />J 4 /Yr <br />moo, v G F <br />CHECK If E3ILLING ADDRESS ❑ <br />BUSINESS NAME lL LoC�� <br />„ � oM� _ _ <br />PHotlE It FIT,1 <br />(2vg) 3�� 'M& <br />HOME or MAILING ADDRESS Q s� <br />FAX It 2 <br />7�S—�I qq <br />CITY L 07j)( <br />STATE C A zip 5 SZ 0 <br />BILLING AC:KNOWUMGEMENT: 1, the undersigned property or business owner, operator or authorized agent: of same, <br />acl:nowiedgc: that all site and/or project specific ENVIRONMENTAL HE-A1.i,it DE ARTMENT hourly charges associated Mdi this prokxt <br />Of- activity will be billed to me or my business as identified on this lona. <br />I also et oily that I have prepared this application and that the work to be perlorinal will be done in accordance wish all SAH .l moulx <br />CCoU.In, Orchlialice Cocles, SteHulards, �i ATI` an 1^11-DFRAL laws. <br />\PPLICAN'I''SSIGNA'IURE: _ DATE: <br />Pa -rat -m- / BusINl:sS 0wNKit ❑ OPEtt, ort/ IVIANAGLR)–ib 0.1-IIr:R Alrrnortizlin ACIiN•r ❑ <br />U'APPL1C:IA17- is Hal the BILLINGPARTY, proof of airllluri;.rNiuH to Sign i.V required l7rlr• <br />-.0"I'H0RIlA'I'I0N •1'0 RELEASE INFORMA"PION: When applicable, I, the owner or operator of rile property located at the <br />above site address, hereby authorize the release Dl any and all rest'[(!;, geotechnical data and/or environmental/site assessment <br />ilticirnlation to the SAN .IOAOUIN COUNTY ENVIRONMEN'rAL HFAL'('ll Di-PARTMENT as soon as it is ava, rk�,�rrcJp EI Dsarrlc time it is <br />provided to me or lily reprosenlativc. R�`T(C�tvv�tF)�� <br />TYPE OF SERVICE REQUESTED; � g�_ <br />1lLfi��,.y►y��' <br />„ � oM� _ _ <br />JOAQUIN COUNTY <br />SAN <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE It: � <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE it: S*413 <br />DATE: / G <br />bate Service Completed (if already completed): <br />SERVICE CODE: <br />I P 1 E: �� C <br />1 <br />Fee Amount: <br />Amount Paid <br />���� <br />Payment Date <br />l<<o� <br />_ <br />Payment Type <br />Invoice if <br />Check It <br />Received By: <br />E -1 -ID 18-02-025 Slt FORNI (Gcdrlen Rod) <br />f!EVISED 11/17/:2003 <br />