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04/04/2005 16:30 2093694248 -,NEIL ANDERSON ENVTRO PAGE 02/0 <br /> 04/04/2ee5 10:53 4640131ler ENVIRDffNTAL ►A,•I PAGE 02 <br /> SAN JOAQUU4 COUNTY ZTiM0l M !gTAL RLAkLTR DEPARTMENT <br /> SERVICE REQUEST <br /> Type of pminm or pro" FACpJTYD! =$.ERVICE RE ST# <br /> avnE,�,OIIErAToR <br /> Gtr if[�JELAMGAO➢Re$$® <br /> ersh _ O Mr-Tim Pad® ae <br /> FAtatnY Wine <br /> Sid to - 0 WE ronArtv <br /> WE Ae0RE% 2677 ZUCkernran Road, McDonald Island Stockton `�7Z< <br /> Home or IIIALm AnoRm (tt Ddtumn team stto Aadren) P.O. Bon 844 <br /> Cin STATE xm <br /> swr&oj) <br /> Peolafft <br /> RA'. APHA l.nao UBE ArPucanore <br /> 1 1 0-01. 57, 3 <br /> PltosEti2 Ex*. nos Ors*race LocAnav Oaoc <br /> ( � a <br /> CON'T'RACTOR/SERVICE REQUESTOR <br /> R'egUESTOR L'1teCR M.)}t6LC+_G Aatatttaa t,+r <br /> have AWkji <br /> I atta,�raNARre - � <br /> i F <br /> Y.CWWVXLa:.ADoRFsss FM0 <br /> r— 9il? Industrial Wily 4209)36_QAM_, <br /> cm <br /> Lodi STATE ca 719 ___ <br /> rs{L�,31YG ftjjOt"NLa" RNf6NT: 1, the undam9nod prop°rty of Aastum miter,%mrstor or aatkoroed agent of same, <br /> acknowledge*bat an 9itc and/or project SpeCI& ENVIRONNWWAL HEALTH DnrARTMI NT hourly 647g5 aa9oclated with this Project <br /> or wttvity vV be billed to me or my basioess as identified on this loon. <br /> I also certit;that I have prepared this application and that the work to be performed will be done in acw6anm with all SAN JOAQUIN <br /> COLm,ry Ordi•a Coder,9randmda,,STATE aid FEoERAL laws. <br /> APPLICANT'S SIGNATURE: , rr�� � DAT9: y— 4/-!5 <br /> Paoez-rrr/r3kS;nMOwncR0 OrERAMR I MANAGERN OTFmR AirmuRraw kolerrr 0 <br /> 14-AFI&rAN e5 not the dU29E M proof of ev&or4mbon M stn to r4gatred rff/rt <br /> [THOiLrsAnQlt T4teE INPORDLATIQN:When applicable,f,the owner or operator of the Property located at the <br /> abwc site address, hereby authorize the teleam of any and all tosults, geotdobttical dam and/or environmental/site asseurmalt <br /> i,fornation to the SAN JoAQtxN CaUwY ENVIRUNmENTAL HEALTH IpFPART Mi5NT AS won 9,t it is avaliablt and at die Cama time it is <br /> p:v6dod tc me w my representative. <br /> TYpR of 8EWACE REWIESTS: SOO Suitability Study Review <br /> Colana' Please review tha following Soil Suitability Study. The Client wilzccau <br /> service review <br /> fee of$186_ if you have any questions Please call, yQr �Q <br /> APPROVER ar: C)L.t V,E t t! PMIR.ovRe N. D,3 z-I DAtc: gee[ s D S <br /> fUiM S 0 S <br /> Assianso To: 1E SC o-�-0 6HPLtrYLM M: ;5"!�<-F `{ <br /> Data service completed (#akaady cow NW); StmsceCaoe 6 22_ P iE£r 2(n•O <br /> Fee Amount: L,,�.. c:. Amount Paid Pt ant Dow <br /> Pa MVWTypo IMMIce IF Check# Reeclred ey: '( <br /> EMD M1C-0t-025 SERVICE RE613&i'PCRM <br /> P.WSED S•s.oa00 <br /> PR 5 2p�5 <br /> SP,JOP¢ONMEtn EN, <br /> tl NTN DEPP�M <br />