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Y 05;x^24!21313 15:57 454E7 <br /> Et11�`iRr-AME;N A- H f"� "" r_ PAGE �1 <br /> SAI JJI i31f>` WNW- <br /> -COUNTY-ENVIRONMENTAL - <br /> y s"' QH�;nr✓ rr nrrnrar . <br /> SERVICE REQUEST _ <br /> Type of 8asiness or Property — FACILITY ID# SERVICE REQUEST# <br /> V�� 1 <br /> OWNER 1 OPERATOR <br /> EDWARD PESTANA CHECK l+BII.uuriAIonEss� <br /> FAMITY NAME <br /> LIVERMORE ACRES, INC. <br /> F <br /> We E BRANDT ROAD LOCKEFORD 953 C711 <br /> 13751 Slrr.t Numter D rrcgon "ret Nam <br /> HOME Or MAlt INC Atft)RE55 (If Differertr from Site Address) � <br /> P'0. BOX 1916 Street NamNer _ ret Nome — <br /> CriY STATE LIP <br /> 95336 <br /> MANTIECA <br /> PHONE#j Ert. APP# l AND USE APPLICATION N -- - <br /> -- (209 U39=5.0.33 Y _ -_ . 0.19-0.6.0=29- _. . SU=0 <br /> PHDNE#2 Exr. AOS DISTRICT LOCATION CODE <br /> .4209 ) 601-2337 <br /> CONTRACTOR ! SERVICE REQUESTOR <br /> x, atQu>s7aR JOSHUA ELSON CHECXif131LLINSADoREsS13 <br /> 4. r <br /> $RstNESs NAME BAUMBACH & PIAllA, INC. ¢?09 368-6618 <br /> Hata or MAILING ADDRESS FAx r <br /> 323 .W. ELM STREET ( ) 368-6610 <br /> , <br /> ctTY LODI sTntCA ZIP 95240 <br /> _I1,T_,T(_G A — _' 1, [lie tnders. iicd propert3, <br /> at I;is tirress owtier, u <br /> eraitiror' AIJ,Orilctl n9etil of S1111t, <br /> , <br /> acknowledge that all site anti/or rrnjeei spcciric l?NvmC)NMLNTAL 1-lrAi'm DT pAtCfM rNj,hourly tharges assncaaied with this projcC.t cal <br /> activily will be billed to me or my busirTcss as identi5ee on this form. ; <br /> 1 wino certify dint (inive prepared Iiiis application zinc!that Ilse work io be rcytot-med will b,.(lane in acturdance with all S.1N JOAQUIN•� <br /> COtlhirY Ordinance. C,orfcl,Srun110711,STATr and Fes lsvrs. <br /> APPIACAN`T^S SIGNATURE: DATE, 5 10 3 <br /> sN}:rtiCvrOTtirRAtsTrroa,T.FnACENiI'R0I'FItTY1R1+ TRrtAYONIMANACWk CK O <br /> 1f',41,'l.tr.ANr is nai the 1>"N.—ix ci PAR7Y proof of nnfisotiw 60it to sigh ii'r,eguirt'd Tirtr <br /> AlJTTIORTZA'T ION TO RFI,FASF INVORMATIO1V: When applicable, I, size Owttcr or nperntor of rile property locnscd tit the <br /> above site srtltlress, hereby nwlzariLe the release of piny and all results, geoicchnieal data a:i&nr trivironmeniallsire ;sssess-vit , <br /> it+e SAN IC;AUUrra C�tst��'i Lr;vrrcoxAtt'�'TAi. 1r�•.�I:rr:•Jt;r.€t'ratl;"r.as sror.«s it is avriilobic Ind nt.thc_sonv tis»e it is <br /> provided to me or my mpreseni:tlive. � <br /> TYPE OF SFRUIGE f7EQUE5 W :�L� -�rl� Hare tzAlhj/7 <br /> COMMENTS: <br /> REVIEW OF SUBDIVISION PLANS <br /> J��4HS���ICbV� <br /> 5PN�1Cl�EP��Ep1Z1'•� <br /> p119 ��NSI�G # <br /> Api�r7LlvEo uy: EMPLOYEE lr: TATE. -0 103 r <br /> AssIDNtoTo: /.CJ/� EMPIC>VEEn: fp DATE. 7 21Q-3 <br /> Data;Service Compleied (if aireadv romwieted): 5ERvIct COLIC: �is PIE: <br /> VOL Amount: r/ Amourit Paid $ 4-7$i Payment Dale -7 gf()3 <br /> PaVrnont Type lnvoicC rF Check 9 !Q 23 Received 13y: t <br /> END 48.04-02b ( 7 r (� /� SERVICr REQUEST FOAM � <br /> I41=V15Ei?f�•'.'"•Q7 j 1J 4'W iJ � ��� <br /> --------------- <br />