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'< +-05-0-5 11 :26 Morl Civil Engineering E09 3-5044 <br /> 06/s0/20FJ5 1.4:49 4646 ENVIRONMENTAL F T_TH PAGE 62 ; <br /> l SAN JOA�UYN COUNTY rNVMON1 ,[+iNTAL HEALTH DEYARTmzNT` <br /> '> SERVICE RITQUEST f` <br /> Type of Business or Property FACILITY[DO SERAtE fiEQUEST 8--- . <br /> -z S <br /> OW04ER 1 OPERATOR <br /> Wayne Crai - Sandhill Development. r tre r. <br /> FAC�ItY NAME ' � T <br /> Clements Oakrid e Estates LLC <br /> SITE ADDRESS 18327 E. Hwy 88 Clements <br /> Nufabgr Z <br /> HOME Of MALMO ADDRfSs (if vif cent from Site Address) <br /> P.O. Bax 1070 <br /> N <br /> I OTY <br /> Woodbridge <br /> CA 7A� � 528 <br /> PNORE lm Exr. APN S L MQ U APPUCA7WH S <br /> 4 209 l 327--2222 019-220-2614 �3OOSr'a cj <br /> PWM,92 nos 017RIp1 LOG1110l1 con <br /> €€ 2091 321-6855 <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUEVOR t crctf@ pffi€p� <br /> ,Teff Mor Zan <br /> P►OW1 rxr. <br /> glgo Taln Cvil En ineerin 20 223-1441 <br /> k "ous or NArL o ADDRESS FATr11 <br /> 504 Broadwa 1 (209 ) 223-5044 <br /> CrrY Jackson STATE <br /> B : I, the undctsigncd property or banjoes o"wr, opet'ator or authorized agettt of same. <br /> a4wh ,ledge that all site aad/or pwj ect specific IFIL MIN[WrAL HEAL-m D>PAR'rntsN'l'hourly chug"0330mt6d witlh this project or <br /> activity will be billed to we or my business as idwttifted on this form <br /> I also certify that 1 have prepared this application and that the wale to be performed will be done in accordance with all Scant JOAQM <br /> Cotwrx Ord dance Codes,Srandards,STATE and MER&L 12-s- <br /> APPLICANT'S SIGNATURE: ri DATE; <br /> PR ?+OPERTY/)3USPWM(� mO t?rMATORIKMAGYA [..a OMMAUTHORMWAGW'0 - -• <br /> IfAPPLACA- T rs"I the proof of authorizadon to sign is requked rifle <br /> , ,TJTHbl�2�i ON x`O TiET.1tiASE>�ik'4DiMA1TON:When applicable,1,the owner or operator of the property located at do <br /> above site address; hereby avMb ice the release of any and all resutts, geom bnicAl data oad/or enmiror�omcntaVsitc nswssmcat <br /> informstian to the SAN JOAQUN 0()UNrx E,WMO nMMnAL.HEALTH DsPARTMM4r as soon as it is available and at the same t�it is <br /> provided to arae or my re prtsentative. <br /> TYPE OFSENCERFQussM: LC 0,4- r O t�rR.S� �L,4•.) GF-[E c•fL <br /> P,ECE <br /> COMMEbre: S" ' „ es le �� �>�vp }UL 5 20D5 <br /> . * $AFJnu � soAoUir3 CO <br /> S ViEAL"DPAPI�M <br /> Acc�7srs Br: IEMPLwrE f9: O3 Z f DA?E- <br /> Aas�GNw ro: �.-( rf3 r N Ll EMPLavar a- 53 les fn DATe: -7 $ OS <br /> Date Service Completed (Il alreadyt comp:etod): <br /> Sem Coal ,SZ Z P 1 E: 4(7 o, <br /> ("ee+Afttaur+t: j�`(�. p e'7 d * j gL ,p p <br /> Amnon!toaipayrreent Data -j s�O <br /> AaymentType <br /> hlve�lee P Cltecic s ` Sr Received By. <br /> r <br /> SR FORM(Gordan Roll <br /> f=HD 4,x.-02-025 <br /> ndnC¢n��pT/fM'! <br /> k <br />