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94771753 PAGE 02 <br /> 03/29/2005 ll Zua 1Y:55 FAL 26515JI29"470 JA5 CONSTRUCTION 11002/002 <br /> SAN JOAQUIN COUNTY ENVMONMENTAI HEALTH DEPARTMENT <br /> SERVICE REQUI ST <br /> Type of Dualities of prapa FkD[Lrrr ID N SERVICE REQUOT 0 <br /> SA 0% T A 000 2 k l <br /> waN1111/OPERATOR CWCK it B%LfNG•eoasee <br /> FAt2unNAM1 � 'LIV Vl O �� � $"' S S <br /> Ors ANKEu p { W 4 v^.l lno 1-t 01-- Soo c.k r/m 9 s 2 t ct <br /> IZia code <br /> HOW Of MAILING ADDREH (Is Dlnennt Wnn atN Adanael <br /> M <br /> CITY BTATe L► <br /> MONEE) an. Aryl a LAND USE APPLICATON e <br /> 1 ) <br /> PN IRE12 aR. BOE DNTRICT LOCATION CM <br /> l <br /> CONTRACTOR SERVICE EQUESTOR <br /> REDUEsTOR V � Yj E �R 2.IL- cuaacuDaM � <br /> Swalwe NAME V L CrNl\ <br /> ►NGt t r E" <br /> HOME or MMLMD ADORES$ FARE <br /> 5 � Iq (SS 2R '1 — I463 <br /> STATE c zip 93 ,6 <br /> I, the undersigned property or business owner, operator or authorized along of Same. <br /> wknawled;a that all lite and/or project specific ENVIRONMENTAL HMTN DEPARTMENT hourly chargee Eaeeciated with this project <br /> or eedvity will be billed tote or my business a identfFled on this forrn. I <br /> I also cerdly that I have prepared this application end mat the%pripw be perfohnsd will be done in accordance with all SAN JOAQUIN <br /> COUNTY"Ronne Co*S�Stondae4e.STATS and FEDERAL law <br /> APPLICANT'S$WNATUM: DATE: 3- 2 9 - ,S- <br /> PROraafl'/BLNNNESs AwNE1a O►aaATOR I NUNAGrA C3 UTNIRA ROa=l)AGENT❑ 0a 0t/ir Az <br /> rfA?PLlC1AIT U not ON 81b1/NGPAR'R'.prooJoJeNrAalrnHOn si(alArsqu/red rrlle <br /> AUTHORIZATION TO Rat R! E INFORM& ION: when applicable,I,the owner or operator of the property bcq(ed at the <br /> above sib address, hereby suNoHu the release of any and all regalia, goaftchnical data and/or env1r0nSn4tegV#t0 3lslesament <br /> UXOMICiC*ID die SAN JOAQIIm COUNTY ENWRONMENTAL HEALTH DEPARTMWT as soon as it is available it is <br /> provided to me or my npr#Maative• •, <br /> TNWOr BERME RWASM: <br /> CoWW a' QUIN GO""" <br /> (, <br /> SAN 30�R"ONMFN-TAL Dow NT <br /> NS <br /> DATE: 3\ O <br /> Ataloa[D TO: �E EMRLOWN M. pct <br /> Dale$s ifts Compiabd W eesady eaaPleteal: FERMI 0001: =i\ iE: <br /> I"Ansoitnt: 1� -7 Iunt pstd -6--/'(Y_oat Payment cam 3 31 O 5 <br /> Payment Typa N/ Imdur* (?j I �'v,P CheeN Y ��� Rece"d 6y: L <br /> END IaO2.026 SR FORM(Gos M Redi <br /> REviseo lin Tia (-��clrk)_ PAYME T <br /> n RECEIV D FF'Pr_ D <br /> 1-� R - <br /> cV-0 � .7 APR 6 005 <br /> SAN JOAQUIN UNTY JOAOUIN l'�tlr' <br /> ENVIRONMEt�TIAL SAENVIROt4MF-NTA' <br /> HEALTH DEPAF7II MENTI LTH UEPA �RT <br />