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SAN JOAQUIN COUNTY ENVIRONMENTALHE <br />A I,T.pEPARTMENT i <br />SERVICE REQUEST 1. <br />SERVICE REQUEST # <br />FACILITY ID # <br />hype of Business or property t70� �� �• � i <br />F4 <br />l� <br />CHECK If'BILLINl3•ADDRESSC] <br />+ + OWNER I 0 MATOR j <br />w <br />_Y <br />a x at to ai �At ILIYIf NAME55 <br />7f yt.. 9. .. ....• ` - <br />t j $Ir>_ Audr£�ss I Vit:t nZ P a cityZI <br />•a�, Street ame 1 <br />+ StreetNum6er Directlo j <br />:Or MAILING ADDRESS (if Different from Sit Address) g e am <br />Iia ,4 ti Street Number ZIP <br />,r j +� .• STATE <br />LAND USE APPLIBATION #• i. <br />ExT. APN # <br />ONE <br />L BOS DISTRICT LOCATION CODE <br />M <br />EXT. <br />CE REE <br />USTOR <br />CONT . RA.CTOR / SERVi Q <br />-- <br />4+r CHECKIfBILLINGADDRESS <br />t EUESiTOR; <br />Exr. <br />`a AME", <br />y.'.'..•%'�I'.:.-:,rk:•.,.,;.vh,:;';:.+ r..: .. .. FAX# 1 , <br />tl�olNEbrNiAluN�ADDRESS <br />y(e <br />STATE'. ZIP <br />( ) f <br />{$ 7 OITY 3 <br />erator or authorized agent of same, <br />B ZING AC1 1V��VI.T>(flGEME ;' I, 'the undersigned property or business owner, °l char es associated with this project or <br />' ect s ecific ENVIItoTIMEN7N-HEALTH'DEPARTMENThourly g <br />r ac�Cngwledge that all site and/or .oj P. , <br />��� aetiuity will;be belled to me or my <br />ess.as identified-on-this.form <br />'6:. ce tht.I'have.prepared'this application and that the work to be performed will be done in accordance with all SAN JoAQUIN <br />ltalso y .. (� ?1AZrds, -STATr., and. FEDERAL laws. <br />x ���� Qrtlinance,:Cod�, _ <br />DATE: ' <br />A .PLICANT'S SIGNATTJRE ,Gt„o ,rw��c t 1'� �� v <br />�4 UTHER' AUTHORIZED AGENTIA <br />OPERATOR / MANAGER I 1 , <br />PiI01!$RTYi,BUSINESS OWNEItLI <br />-4 T. ANT Is not• the.gILLINGFART, proof of authorization to <br />signis required Tlele <br />a z, •' -., O TION When applicable, `IL the owner :oc_operator of fheproperty located at the <br />�'' �' � �� _ T 'YUE, -�E ase'�'an ,:anc) .:alb xesults, •.geoteclinica data an�%r environmeiita�75ite assessment <br />:.. <br />� :� _�� ..'� •.• ENT.as soon.as it is available and. at the -�= <br />--time It is ._.._---. _ �jb�a�•�i�e address; `lierti y au oxIzt= ere F.., y _--..-- --------------- <br />( �, +�,r � � AY„ ggAi,TH DEPART1vf <br />• ;max � t)•m e DI <br />'(p�44..rt v. t�,'e -4 J J. ••.- <br />ERVECEREQUESTED <br />\i✓ �. <br />EIVE® <br />PEF = <br />t. a o MENfij 7F <br />JUL 1 7..2013 <br />srl 4oAauiry couNTv- <br />,Nv, �: 5 � , ,, <br />ENVIR.OMENTAL• <br />_..; .. <br />HEALTH DEPARTMENT. <br />2t�1Ya1' a <br />e <br />EMPLOYEE # ' <br />DATE: �r <br />DATE. �. l3 <br />EME #` <br />PLOYE <br />i <br />�iNIJ TtiCODE:r <br />P1 E: 3 <br />to t Ice;Completed f alreadycompleted) <br />SERVICE 1 <br />payment Date <br />�!� #3 <br />L, <br />Amount Paid': <br />Check <br />Recetved.By <br />' a Y.J mit <br />I,nvote <br />