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B-2-43-1998 3:58PM FROM <br /> — P 2 <br /> • .. � SERVICEREOUEST' <br /> Type of Business or Property FACiL1TY ID# SERVICE RE UEST# <br /> 9 - 8264 C� �-7 7/1 <br /> OWNER/OPERATOR (� I <br /> RSr1 Pro CX•Kcks BLUING PARrTX <br /> FActurr <br /> SITE AORsS 75 TY . 9. 4311 . <br /> rove <br /> Mailing Address (R Different from Site Address) <br /> P.O . Sox oo . <br /> CITY SCI..` Pcx wc, \ STATE(f:A . zm 9¢583 <br /> PHONE#1 CIT• ,MPNT A c-r# - LAND USE APPLICATION# <br /> NZ5) 842- 700z 14 a 46 - S <br /> PHONE 22 Eszr. SOS DwrAcc L.OGAT1oN.CmE <br /> CONTRACTOR!SERVICE REOUESTOR <br /> REWESTOR B61AYG PARTY❑ <br /> BusaNEss NAME PHONE# Etr. <br /> ` AC- (70 745-- 66o X44a <br /> 11AnntGA01 -7 No Dow !l B l�� FAX 7155- &710 s <br /> Crtr 1 e-+eL STATE CA- ZIP '74— <br /> BILLING ACKNOWLEDGEMENT: I.to ure,*w property or hucanc mNrar,opvator or au fwrard agent of sam4 adu w cadge MA CIE ste ndtor paject spedYC <br /> Rmuc HEALTH SERv"S EVVIROWJENTAL HEALTH OM PON hWrly daMw as:adald wO to pojeCorOOb*wi be hied In me or my b sLress w ideM'fiadon In LNm <br /> I also certify tat I haw,prepared to appSMSM and twit tbA wade to be will be done in ac:nft�wBh a1 SAN JaAaIW Cwm Cafm=Codas Stmdwds.STATE and <br /> FaaEML laws. <br /> APPLICANT SIWATDRE: DAM- <br /> PROPERTY/&ADIESS <br /> AMPROPERTY/&6MESS OWNER ❑ OPEAATaRf MMANAGER ❑ O[NERAIfDaa®AGEN[ ra'VrAAaa r �0� C �� <br /> lAPP1xANranofdar peddwM6vla/s roagals YiNt <br /> AUTHORIZATION TO R :When appfirabkL L tr a wapenmr d dw property habit at tae above site addtaes,Mreby a ftft to mese ef <br /> any and at nesuhs.geoo dnad data ardkf envC %rodNfsife assestmem btaraaBLmr b Ue SANJaAo m County Ptum HEALTH Ser4icEs EwAomi [OALREALTH OMSIWt as loon <br /> ac 3 a aua4bN CIM at to sane title 2'a provided to meat my rapeserlCtle. <br /> TYPE of SarAcE REaLwTED: <br /> COumrts <br /> ��.s�-a\\ ►.�.� 12oot 300 <br /> RFrw5vr- <br /> 41"? <br /> NOV 3 0 1998 ED <br /> p <br /> SAN JOAQUIN CUJN is 98 <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH OiVIS" NTY <br /> H S <br /> btgEcrooes 9GNATURE COM[NACTCNeSSrRA7Wf£EN'✓I <br /> APPROVED By: ��. f� � Em zy,--#- �Ass3GxEO TO: � ornrsc#: . / <br /> Date Senior Completed (B aboady comped)- - SEmcecooe 3 6- pre <br /> Fee Amount �-3 L Amount Paid �' Payment Date <br /> Payment Type L h[wiee# Check# j��� Recdved SY- _ <br />