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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENl' <br />SERVICE REQUEST <br />Type of Buttilwas or Property <br />i )-�a <br />C/ECRRBa1rMBAOp�LJ <br />ID 8 <br />SERRVICEERREOLEWi <br />_ l <br />IS Il i i1 l UC.I I t `i- <br />y� y�FACILRY <br />I'7 V Ci��� 6 <br />1Se,,CC+-72C1 <br />OMIIER / TOR i <br />i <br />�i ri <br />I''I <br />R7EUT B BILLaw Atleaatl..Il <br />FI) <br />FAa <br />WEADwtEas <br />`QG.P r �l <br />MQ r Ir�cSCi <br />�� <br />�jc iC }a n <br />S SCS <br />J <br />JUN 2 3 2006 <br />W Y WMG ADDRESS (If DRfera�r[ from Site Add..) <br />l(.l-jU� <br />Strwt NunrMr <br />I {-I v d ' <br />LJJ6-4r-l rk <br />ATE ZtP / 3 <br />�) 31 l� a� Exi <br />[�� 11 <br />APN a <br />LAuo USE APP ATIUN 0 <br />PIMIES2 Exr <br />( ) <br />c:WrEE te:P25d <br />BOS DISTRICT LOGTant CODE <br />CONTRACTOR / SERVICE. RF,01IFSTOR <br />n <br />i )-�a <br />C/ECRRBa1rMBAOp�LJ <br />N <br />E <br />PtMIE• ts. <br />K1 <br />i e- t Zih <br />; <br />_ <br />FAa <br />D3 N. <br />`QG.P r �l <br />Cm' Il <br />STATE ZfP <br />wa.r.aNC; AC:KN W Saar=arMFNT: I, the un&e igned preperly or butiuees owner, epeeamr or authorized aAeut of ar,. <br />acknowledge that all site and/or project spc` ific f.NVIRONMFNTAI HFAI. Tit DrPARTMFNT howdy charves associated with this project <br />or activity will he billed to me or my busiatse as identified on this lurot. <br />I also certify that I have prepared this application and that the work to hx performed will be done in accordance with all SAN JOAQM <br />COUNTY Ordinance Codes, SaordurdT, STATE and FFDFRA! laws. <br />1 <br />APPLICANT'S SIGNATURE:;�.tii _ DATE: <br />o <br />PRrf1 :tr / B(1,MNM%0Wnefl� (i)rutA / L <br />XR 13 OTHM AtMKMUZ1 uAGENT 13 <br />// , IPP/J( ANT a not the B/LLING PART), Proof ofawhorman- b si n iv , minhd TiNe <br />RUTH MIZATION TO RLLLASK INFORMATION: When upphiabfe, 1, the owuer or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />intiumation to the SAN JOAOUIN COUNTY ENVIRONMFNTAL HFAI Tit UFPARTMF]'T as sown as it is available and at the same time it is <br />provided to me or my representative, <br />TYPE DF $PI E n la� b1,pnel <br />i I ,. <br />E <br />P4 r= <br />; <br />J <br />JUN 2 3 2006 <br />ENVIRO M Nf HEALT <br />PERMIT/SERVICES <br />ENVIRONMENT HEALTH <br />Acce-reo BY: <br />c:WrEE te:P25d <br />ABNOMM TO: <br />EMPLOYEE *: ,,;? <br />Dale Service CompN/ud (B already curaPYaad): <br />SERIMCE 60M:Fee <br />Anwtat r <br />AnatolePaid <br />1�� OU <br />PeymarN Type <br />I voice •Com. <br />3 S <br />END 48-02-025 <br />REVISED 11/172003 SR FORM (GuMan Rod) <br />