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Y ♦ �� iyY �'1 , M Y A µ bF" f4i s <br />,,, y „-,'•x ' ; M ; t } r.�' " 4 Tti'_1 <br />w " . x •r;, <br />s t <br />SAN JOAQUIN COUNTY ENVIRONMENTAL REALTH DEPARTMENT <br />SERVICE REQUEST " <br />i <br />Type ofBusiness.or Property FACILITY ID # SERVICE REQUEST # <br />T FA <br />66 3 s <br />01(1/NJrk2 / -,OPERATOR . <br />� .�-"ate, ;;.:,�,.,...�-•� ;. •. ...... ...... ....:_..._ -., .:..., :.,. ...... _ . CHECK <br />if BILLING ADDRESS <br />EI <br />�,p4n f`A'L'ILITYKAME ; . <br />kA = SITE ADDRESS 25 1 6-Ma 160 Fld . V IUMtn <br />C <br />Street Number Direction Street Name Cit i Codev <br />HQME or MAILING ADDRESS (If Dlfferentfrom Site Address) <br />•.:. - Street Number Street Name <br />`iT1` STATE zip <br />s t $T110NE # I ' APN # LAND USE APPLICATION #- <br />A <br />'xn ``PNONE2.T BOSDISTRICT LOCATION CODE <br />C TRTACTOR / SERVICE REQUESTOR <br />REQUESTDR ` <br />- .. <br />CHECK if BILLINGADDRESS <br />'Br -SIN =Ss 111ANIE r PHONE Exr <br /># <br />iOIVIE �rAiLING ADDRESS FAX # <br />a_ CITY ; STATE ZIP <br />_ BILLING.A'GB TLX. DG•E&ENT:'I, the undersigned-property or business owner, operator or authorized agent of same, <br />,:- . _. aollarnowledge that all sxte:and/or project specific 1;NVIRONMBNTAI. WEALTH DEPARTMENT hourly charges associated with this project or <br />''r acta`nty will-be billedAb xne or my:buslness,as identifed-on-#h s.form. <br />u.. _... <br />,:a so: ce - that Ihave re 'ared=,this <br />-application and that the work to be erformed will be done in accordance with all SAN JoAQUlrI <br />y p P PP P <br />oUt�ITY ardrnance Vides, ;fandards, STA7CE andFEDE1;ALlaws. <br />A_ • <br />A A>°"I�"iGANT'SGNATUE!'f 1I1�1 �4���( <br />t7 <br />DATE i9� J l <br />- AT <br />E: <br />,. ROPF,RTY/�USINESSOWNER OPFxA-Tok/'MANAGER'G� OTHLR'AUTHorj&DA.GEN1 <br />�— <br />ff.AP,PLIGAN .is not.the BmaNGAiRTY proof of authorization to sign is required Title <br />AUTII#OR T 'To LEA-SKINFOItl!'IA-TION:-VPh&f4pplicable;"TLthe,oyvner or operator of ftie�ropert� located at the <br />- <br />',�=-.=•ebow�slfe ad r'ess 73er su oriz� a release of an ..:and _all results'.. eotechnical :data .an or .env�ronmentaUsitti assessment <br />:-�.�iT�i3tioii�tc##�he�EiN JDr�QU1t� GOurIT'Y �VVIItOIVMENTAL IiEAiTH DEPA1ZTtiiEI1`I`=as sooxi.as itis avazlabie and. at the saxne.tme it-is <br />�' . pr©xitie`fl to rile or .xny irepreSentafive _ --— <br />t:. <br />s - E ERv1Q11ESTED <br />+ @�DMMENT <br />41V 08 <br />s�V <br />rt �i <br />40 <br />ti wr°20' <br />c <br />A <br />��L....7 <br />� _ �ACTy o MFN oU n, <br />...x • - <br />K� l���EPTBDBY EMPLOYEE,#: DATE: t <br />X sti k " <br />$$IGIVE[xDO _ _ _ "EMPL1iYEE [' -DATE: <br />psite $ervlce Cornplote�i (Ifalreadycompleted): SERVICE CODE: P/E: <br />swFee Anot�nt Amount Paid '� 1'ayrrte Date <br />•` x � 1 � . ��--�/ — 4 4 1 � t x,1{' (� tx - r `•`:.4. i, w 1 t x 1 *r .. f { � +�t p. �q 4 <br />