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'04/05/2006 13:38 505-286-0990 ATEAM CONSULTING APR 04 2001 11:33AM LASERJET 32130 SERVICE UQUEST I) e z �e PAGE 02 p.2 Type of Business or Property CNECK it Bf,,l LINO AEI -0 9 FACILITY ID M SERVICE REQUEST IN L I3 S -5''oo q10 ;290 O / E FAX N HEALTH p ME CI s i CHE'CH It BIl I U'0 ADDA ESE FAORItt NAME I O All IlNr. srWM^ws e•... -.,......T 11�,yJ B Q rte1. V' Date Service Completed (11 already compteledl: SITE ADDRESS e r NOME or MAILING ADDRESS III Different from Site Address) SERVICE CODE: ke Fee Arnourt 6t> Amount Pald Qlr/ STATE I - zip - PHONE FIi Ert. A,pryo LANG VeI AEPlh4f10NY PHONE eY Frq i I DOS VIa1AICT LOCATION CODE REOUESTOA CNECK it Bf,,l LINO AEI -0 9 BUSINESS NAME PHONE E Eer. HoMa 6 or MAI C AD RESS FAX N HEALTH p ME CI s i EMPLOYEE D: ST I O All IlNr. srWM^ws e•... -.,......T DALE: J W . e, me uneeratgne0 property or business owner, nphator or authorized ngenl of yunrv, zcksw�%ledge that all si le and/or projcet specific ENVIRONMENTAL HEAL I'll DEPARTNSNT hourly charges assoc ialed wi hh this prujcet m activity will be billed to me or my business as identified on this form, I also Certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN IOAQUIN COUNTY Ordinance Coder, Standards, STATE and FGOERAL laws. APPLICANT'S SIGNATURE: PAOYERTI'/ DI151NESS OwNaR❑ OPE TOa/MANAGER ❑ OTIIEA AUTOORMET) AGENT .19sw,- eprNA.� 1jdPP/rGINTLYnotrge / / proof o%nrlrhorl=orlonrosign Is. required I/;,r,. TO R$LE.ARe rNFnnnu'rLQN: When applicable, 1, the owner or operator of the properly located at Ila, AUI`1101119�410Nabove site address, hereby authorize the tsimso of any and all results, geotechtncal data and/or envimlunenfnUsite assesmiew infornaaiiun 10 the SAN JOAQUIN COUNTY ENVIRONMONTAL HEALTH DEPARTMENT ad Soon as It is available and at the same lune. it is provided to sae or my represenulive, TYPE OF SERVICE REOUESTED: 16 e-- 12- _,i- T5A t - ---� DDYYEIns: s IVIL-1 Ep APR 05 ZOp6 SAENVIIF? I N COUNTALNTY HEALTH p ME ACCEPTED BY: EMPLOYEE D: D01. Ass10Nfi0 T0: EMPLovee M: DALE: Date Service Completed (11 already compteledl: SERVICE CODE: PIE: Fee Arnourt 6t> Amount Pald q Payment Date n Uw Payment Type Li JOY Ica nva CheckN b132 Received By: rr enU 40-02-025 REVISED 11/17/2005 - SR FORM (Golden Roc;