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FEB 21 2001 1 : 16PM HP LRSERJET 3200 P• 3 <br /> PAGE 01 <br /> 08/18/2805 09:01 20EHD9A603433 I <br /> SAN JOAQM COUNTY ENV1ROr4WNTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of 9usir Or Property FACILITYIDI 6CKVI6l REQUlSTA <br /> dM1aR/ w 'enarx lf6euxO AoeataA <br /> i <br /> FAcam <br /> NW <br /> ea. rx n <br /> NOME or LUUNd ADDRESS pf 0111Annt Mom 61t.AadnM <br /> n.a. <br /> cm Srafe Zip <br /> p, <br /> Pxgyh am APNi LWa WaprruWnoNa <br /> I <br /> PAaa!R ¢+n. SoO�icr LauriaN dooG <br /> ,I <br /> CONTRACTOR/SERVICE REQUEST OR <br /> RF.TMfIaTDp L,Rt]K It @LL nG AODAYN <br /> I f <br /> BVS11E49 NAM" <br /> /C- <br /> lcxkaa.l F1� <br /> Floe OrblnuMo ADDRESS r- / /N f rAf <br /> �ly <br /> C" l�� U BrATgyG ZPO ,fJ <br /> gUjjjNG ACKS2WLVQ9MENT: 1, the undarsilitad property of but7ecas owner,operator of aotbotized agent of same, <br /> acknowledge that all site md/or pmjm sptcllle ENVJRDNNIEWA 1719 v iH DtaARTM®rr bonfty charges aaGmlmrod witb this project <br /> yr WIvlty wit]be billed to me er my business s9 IdaloR.d on Itue form <br /> I alto cud fy the,f bow propu.d this ap etion and thID��m b.periormod will be dont in sceasdanee with 511 SAN JOAQUW <br /> (�OMY Ordlnan.e Codnr,St¢ndords, tl PfD to —� <br /> // _d <br /> lL L:AN3'S SIUNA'['URE: /� --, L'� DATO: <br /> raartRT/BUMIeG�OWNG¢❑ 1eaAlnn/MMAf�eN �. OTnaP ArJTMOWSL¢AGLnrO �: �-Oi'I <br /> lfAPruCar?fs nOUheBLt[)l�Pro°v/PluadfnriaWlan Fo sign UldQu6t0 .� , not <br /> Ajj('jlQ ,iT10N 10 ELIFA 1NFORMATIQ_Nt Whon applicable,1,list owner of opentor of the property located ad me <br /> abo•e site address, bmetty tusthosim the selmliv Or Any cad all rauliG, gmlachaicd data md/or eayironmentaVafte atseesm t <br /> information 10 the SAN JOAQUIN COVNTY EPMR0NWWA1.REALTR DMARTMaNT IN deco I It a avallabie and*VA""Lm"-Ili <br /> psov'Acd m me of mYrcprms mive <br /> TTPC OFBRYIeE REouEStEp: � - <br /> ccaarxs: FEB 2 3 Z01 6 <br /> SAN JOAQUIN COL NTY <br /> ((JJ ENVIRONMENT L <br /> HEALTH DEPARTM NT <br /> Acce"up Be, 6n¢GOve[a_ 3 Ona: Z3 I <br /> I <br /> ' Aayaiap to: C S EN.wraa M: mw <br /> Dau Servl completed Ur akr¢iy 60 <br /> 6 .0'."41; / /E: <br /> kine Amount: 67D Amountpaid �pZ--t Q.p� Payment Date a3 b <br /> i payment Tyv. mvoica i Cnack D ('(O� RacaJvotl By: <br /> ! aR KIRM(Ootlen Rad <br /> NSmeH1 <br /> SED SEo vrrnood <br /> i <br /> I <br />