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15 2006 4: 41 PM I' ,tern States Contract i n 48' 492-5847 <br />SAN JOA.I UIN COUNTY ENVIRONMENTAL HE, ALTH DEPA,FtTNIIENT <br />SERVICE REQUEST <br />T e of Businesti ar Property FACILITY 10 # SERVICE REQU EST 0 <br />P.9 <br />OVYIJEF: / (AFI R >l'Qr% �,1iTCX If 31LLWG Aae4l.3 l' <br />=AGILITY J AM E G <br />LAC <br />>ITE A•DORESS -Tow <br />IQ 515 jweel Number Dir3 street Nene, <br />-IDM= or MAIL911G AE'DRZS5 (If Diff went from Sgte Address) I <br />CITY <br />HONE l ExT APN # _ <br />13 SOME �' <br />E 42 -- jp `Y <br />, <br />city Z.E ccd, <br />qIrle <br />STATE ;:;P <br />LAND USE 6,PPLCATION X <br />90z, ^S-11 CT 11 LOC %T1ON CODE <br />CONTRACTOR / SERVICE REQti ES'IOR <br />4ECLIESTOFG :1-aCx It BI LI4G ADD17E: 5 M::Y. <br />PaDNE :Y Ex, <br />3USIh ;S NAME M-11111 Y� <br />1'iOME0r Al1:NGiDIaR1=5S ,�- I F'°t# <br />CITY STATE �- iMF tT716 <br />BIL11r+1G A,CF:P;OIh'LEDGEMENT: 1, the undersigned property or, business ow>Qer, operaf:or or autborizec agent Cf same, <br />7011 ow edge that ali site and/o>- project :tpeCifiC EN VI. ONI�-NTAL HEALTH DEPARTMENT hoL-tly Charges rssociated 'A ith this :-rojert <br />or activity wi l be billed to me or my business as identif,•ed on this form. <br />I also certify :hat have prepared this appl':catirn and l..iat the work to be performed will be cone in accordance -with all SAN?CAQUIN <br />C0U1`'TY Orcmalrce Cortes, Sfanc!arcLr, STA ---C L lalv'` <br />1,FPl ICAN7E SI°G1PiA7j URE: <br />`ROPERTYi BIISINES$OIVNF.R❑ 0PEFJ,TOR/,%1AN. GER 0THFRAuTHoR1zE1DAGEN1 Li _� E� •J�jl�+� I,p ,gi A � <br />Jt.:i?,PL1cAArr is not the B11.LAQ ARTY. proof of ueclhor�zat�om to sign is reguircil TWe <br />�►_jL_BLZ1#7TO1'i TG4 __J;LFJSE INfORMA.TIgN: Whcu applicable, 1, the owner or operator of the prropert accatec at tk,e <br />above site ad,dres, hereby authorize the release of any and all results, geotechnical data andlor e-1vironmental/site iisse, slnent <br />nfor nation to the SAN JOAQUITN COUNTly ENVIRONMENTAL HEALTEi DEPARTMENT a5 Soon as it is available and ,�AYM�tiir n it is <br />FHO zz-42-025 Sq Rod) <br />?-V, ED 1111712003 <br />TYPE OFSERYFLE PE2UESTED: �SL ��` <br />l <br />COMMENT:;: — <br />_� <br />MAI 1 6 2006 <br />SAN JOAOUIN COON <br />MFNTAL <br />ENVIROE ARTME <br />HEALTH <br />'%C -PTSD 8Y': /„�N <br />R <br />EMPLOYEErJdr: �� X -b <br />PATE: <br />ASSIGNEO TO: j �fj ./ r <br />_ I EMPLOYEE ir: Q [LV� <br />-E CODE: <br />E: AT E: -- <br />PtE.: <br />Llate Service Gert pteted (if already eomplated): <br />SER= <br />a�— <br />=eeArrDUnt:` Amcunt?aidenDate <br />� <br />aaymerd iy e ,�� <br />Check <br />t�sec/ed— By: <br />I -r <br />_i�ve <br />—L-.� <br />FHO zz-42-025 Sq Rod) <br />?-V, ED 1111712003 <br />