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FROM : ❑IL EQUIPMENT PHONE NO. : 209 7545726 Dec. 11 2001 02:19PM P14 • SERVICE REQUEST Type of easiness or Property FACILITY ID# SERVICE REQUEST# OWNER I OPERATOR MILIA4 PAIN 0 Rudy Mendonca FAGatn NAME PajMs Gr SITE AODRE$S E Waterloo Rd. 6732 sh.N xwm« ay.eaee ahenx,m. au4i Malting Address Of Different from Site Address) CRY STATE ZIP PN00d1 E.r. APNA LA.No USEAPPUUTION# (209-931 -6048 PRon#2 en. 905DtsTlucr LacADoxCn a CONTRACTOR I SERVICE REOUESTOR REQUESTOR OLLaa PART Keith .A. Tallia , BUSINESS NAME PHONE# 1w, Oil E ui m 0 75-4-1508 MAUJNG ADDRESS FAx# P.O. Box 950 crry San Andreas STATE ZP95249 BILLING ACKNOWLEDGEMENT: 4 the unassigned property ar business owner,operator or aethorced agent Of same, ad=w Wge MW as site ardor pWd sped PUIRJC HEALTH SERVICES Ew RdrNENrAL HEPLTH ON Itoudy dwrgea as od W wAh tills Projector ac?ri will De b9led W me a my business as iderrofied an this Z11trl. 1 alsooelnfy that I have prepared cis application sod that the edE bed am�Nanos with all SAH JOAOM COUNTY Ordmedce Codes SfaddaNs,STATE W FEDERAL IawS. lL�y ApPU�Tc�NAy�; Keith A li Tales 1/ � DATE: 7/23/01 PROPEarvlBuSINESS OVMER 0 OPERATOR!AtJUGER 0 OTHERAUrNORM AGENT fY Lgan I/Aw•�C+vrsretle BJ•nGPufry pnxfofavdlormtlmroal�re raqured Title AUTHORIZATION TO RELEASE INFORMATION:When apple abte.I,the ewneiror operator of the property k=L`d at the above sibs address.lweby authorve the Ni any and as jcF sa,geetedlnical data arWhr en oranentausile m the SAu JOANAN G7iNTY h;Ri M.Hs U.U7 S2 3IZ/V1Rf o4WfALHfALXI DAM1CH M S* as it G avaaabte and at ave same time R is proyided to me or ry rBpnKen~ttive TYPEOESsmmr REGuRSTFD: Permit application to install under pump containment pans. CdNMEVTs: INSPECTOR'$SIGNATURE: CONTRAmOR's SIGRATURL. APPROVED wy: EMPLOYK iF. DATE! ASsiamev TO: EMPLOYEE IF. DATE: Date Service Completed (N already completed): SERVI'..E CODE: P IE; Fee Amount: Amount Paid I PRyment Date payment Type r Invoice it Circck 9 Received By;