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00/19/2M 05"01 2094683433 EHD PAGE 01 <br /> SAN JOAQ.ULIV COUNTY FNVII-LONMENTAL' HEAL R.1)XPAYtTM.2N r <br /> SERVICE REQUEST , <br /> Type of But:lneal or Property FACILI 10 KK� SERVtrvE REQU <br /> Sf <br /> 330-Op 5 <br /> OWNC 0roR <br /> L'til,G}- CxgcKft <br /> FACIXI'NAME <br /> 0-7 <br /> - !51rrq,�Hl lr _ _ �- — —:,ti Ce. <br /> HONE of btAIL1NG ADDRESS (Ir DlM1branl hOm 8111 Addr.N) <br /> RAmI NIM�_ _ _0 111 Nims <br /> Clrl' $TATH �v zip <br /> PHQ,F Al <br /> W. APN i Lop Ua�l ArAUoAnott K <br /> �2ci—t h <br /> PkoaaF Kl Q'l+, DOS trsnmcl 9 LOCATt�0 CODE <br /> UA <br /> CONTRACTOR I SEWICE,REQUESToR <br /> CNrcx If 1J14tLdRr3�t�ti�4.� <br /> Buslx>✓ss NAM" r PHONE Ir .(� �• <br /> lioM 1VWcwn Amass F0 <br /> U7 <br /> ,CITY STt74 EIP <br /> 13L1, IN, C g Vj�: J, the m-w*tlgnod proporty or btuJness owner, aperotor or uuthor"d urent of same, <br /> admowledgb that All Sl(!And/or projeot speclAC ENVnRONWNTAL KEALYN:)fiPAAIt AMT hOWY Charges associated with this project <br /> or a0lv4y will be Wed to me or My sustno-ts at jdendRtef 00111113 iorm, <br /> I also eatffy that 1.have prt9ued this appliesdA and that tho performod will bt done in aeoordence with 11l SA1v)OAqurN <br /> COUNTY OrdJltanea CddeJa Srondardra 5•r J, aW <br /> APPLICANT'S SIGNATURE+" DA,TCI <br /> PAO►TATVtBUbtwiowmaD ar131TOR/MMA to U9 O1'ItCAAtliy0R11[D�CCHT <br /> !f AP/L/CANr Id nOt rine�( L1Nt3PdRTY,p / uathrrrizplion ro s >f!s regrr✓rett ;rug <br /> A 4 7`IO TO AFI MASE 1NFOA1y�TION; When Appacable, 1,the owner or operator of the propt:rty locered dl the <br /> Rbov site address, herblsy Authorize the release of any and all results, geotechnical doto and/or myIron nkLj,b Vstte a3sc:sment <br /> infotmulots to the SAN JMQUIN COUNTY 1:NVIRONMIINTAL HEALTH b61`An7MeZ4Tas soon as it 1s evRlfa _ptIbLn s,azue airnC 1114 <br /> provided to eto or my/opresemativo. NAYIVa t=l�J I <br /> tYrColsegVlcERegUP.eT6D; Lc.ST �y 7 Uj—I T– <br /> t:orwa,trs: —.-- <br /> FEB 1' 9 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> AQ tpm 9r: C r li r–1 t,�–,� EKaI oYAt it: �� 2_ Bart; <br /> F <br /> GjNeo Tn: ;l 6pf � L De <br /> Service Camplo4d fita ady eompMtedlt 41AVtGe Coos: I C P I E:Amount' q� ,t �) Aanount Paid a o�} Ayment Datamant Typo L,� Invoice ata CtTack p <br /> L( I 3 Reoolvgd By: N� <br /> [HD FORM Go�aah Roa <br /> REVISED <br /> 1T 1!1 72003 SR FORI ) <br />