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03111/2616 10:58 916373.2540 32 MAINT <br /> MAR 14 2016 <br /> SAN JOAQUIN COUNTY ENVlROWENTAL HEALTH DEPARTMEriT ENViRONMENTAL <br /> SERVICE REQUEST <br /> Type of Suninf!ss or Prope FAMITY IA 4 SERVICE REQUEST ak <br /> u- M2qLJL4 <br /> OWNF-P I oPERATOR <br /> �� r T i � �,1� Gn�c�c itswtaac_AopgEss� <br /> - SOMM N•.m�be� 1 Vim.,,,—T.:�___6�eat _,..,... ..,,, ZdP <br /> HOMF or MAu K At>vttsss tit CNNemnt from Site Address} <br /> Urry SrATt zip <br /> prr4N£#t T APN O Uevra UM AlnLta4TION# <br /> sos DISTRIC r I.DGnTtr�i CuoE <br /> _ CONTRACTOR!SERVICE REQUESTOR <br /> ESTOR <br /> $119rN NAME G1 1 '7 Vl�4"V1 PRO 4r. 2 3 . <br /> How:or Mmuuc ADDRE �.� FAK9 <br /> { } <br /> CirY mu . S >t-"c-- - STATE ZI S� <br /> SLUNG ACIt141MEDGEM1=NT. 1, the vndersigrml property or buslnfts owner, operator c5r auftwiZed agent of sort., <br /> advrwrl 9a that vJ1 sit® ontUor project spezific E TNVROtgMENTAL HATH DEFIM"wAENT hovrty cira ger associated %YIM thls project or <br /> 3ctivI#y w!A be t,i%?d to me or my buairsuss ab fderiK*Ca On this form. <br /> also certify that r Have prepared this application arlpd that rt*worx to be performed MI be dune In atx;uvdance vrith W1 5AV JOAQUIN <br /> COUNTY Ordinance Codas,Sfandaras, 7E ot,d Fee laws. <br /> APPUCANT'3 SIGNATURE: c ( T <br /> PROPERTY i l3UStNFR3 OWNER OPERAroR 1 MAtmAGEr 11� 0T9FR AuTRoR=D AGENT 0 _ <br /> !f APrn -AmT is trot tho BILLING PARTY proof of aufhorizariAn to slpn is required <br /> R,�K6DR!I 7 RE E JNFORMA N, Whan.appiicablp, 1, thu owner or operator of t1le propArty locmted at thF: above <br /> sate address,hereby authorize thq release of any and oil results, geolcGhnieal data r3ndtor errrimnmentRVSite aaseSSMent information <br /> to trJ8 SAN JOAQVIN COUNTY ENVJRtNWeM ITAL HEALTH L3EPARtM riT A6 soon a5 if is oval€able and at the soma tlrne it is prpvlded to me or <br /> my reprgssntative. <br /> TYPE OF$e-WCEREQUESSEO: � � aYME T <br /> C9h111EliT$: p <br /> MAR 14 <br /> 'AN-HQAQ[rpr C Y <br /> EN"Ro"E <br /> HEALTH DEAARIn ENT <br /> AcCEPTm By. EMPLOYEE#: DATE: <br /> A95rCaNW TO:- r p Eret�t-oYF.r:#: DALE <br /> ' Date Servlee COMPf6t0d (if already oornpleuid). SEIay10ECOtSE' PTE: <br /> Foo Amount.- _ Amvt,rrt Ralt1 D — Payment Date <br /> PBymerrt ' lvaic1CtOdr Syph (a4t / 4 7 Recstved 13y: <br /> I <br /> i <br /> EitD 48-Q2-= SR FORM(Gokden RMi) <br /> 07197 M <br /> fCf/ :CO .� 39E6 aoeTd19NjeK AjZUnQ3 OZZZl1r680Z1 9Z: Ii 9LOZIZlJE0 <br />