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U Y ! <br /> FROM :BRADY ELECTRIC FAX NO. :19163923925 Nov. 052003 04:30AM P1 <br /> 11/Q4/2®i33 26:23 464 ENVIRONMENTAL HLALTH PAGE 01 <br /> .... .,, — <br /> >�A7 Ak#9,-!Mb5 SAN JOAQUIN COUNTY ENVIRONMET`I'CAL HEAL T'II.Ut;PARTMENT <br /> SERWCC REQUES,jr <br /> Type of®us)nass or Properly FACILITY ID# SMVICE REQUEST 8 <br /> OWNEtiIO —::EAo CDP <br /> PERATOR � <br /> 1� t(2_0 !A1 t'-� caecot trBlu� wEl <br /> FA<tmriiui{E r _ <br /> 5)TE ADgRl:SS �---,• <br /> Lo <br /> HOME Of MAILINO ADOR88 (N biHamnt from Site Acidr®a®► _tdtr <br /> CITY StAT6 ZIF <br /> PNON:ttt APN 0LAND USE AtMGCATION! ^� -- <br /> 1 3 v 3 <br /> PNON[tri aar. wwwwa <br /> no$DISTRICT Lc :AroNCOue <br /> r 1 . <br /> CONTRACTOR!SERVICE REQUESTOR <br /> R>scluasTn <br /> BuaNEss NAME PxbiaE D err, <br /> ,s9itr� <br /> Hofer or MAmG ADDRESS FAX d <br /> y 5 y st- 9� <br /> STATti "P /371 —ac/ <br /> CITY . '�s'7 a . <br /> BILGING AC1tPIOWI.EDC MLNT: I, the undersigned propwty or business owner, operator or anthbrizaiu agent of fame, <br /> Acknowledga that all site and/or project xpecific ENviaaNMEN rAt,HrAi.Tii D[,:PARTMFnT hourly chargca oaaociatad V11th this ptc icet or <br /> activity will be billed to me Of my business as identified on this form. <br /> 1 also eertity that I have prepared this application and that the work to be perfortned will be done in accordance with all SAN.1C AQUIN <br /> COUNTY Ordinance Cr des,Standards,STAT@ and Pm mm.tient. l <br /> APPLICANT'S SIGNATURE. /�' 'J �' �y DATE• /��" t7 <br /> PRAI'KI%TV/11I3Ir4 4ss O'yM0q raawYota!IKA vAGRa ® OTIIM Atrr1IQRizKD AuRKr L _ <br /> /f APPbld:ANT s►ro/the Rn.untc P.tsrr proof of arrNrorizatipn ro SIgN is rrqulrtd rant �. <br /> A[LM(}RIZA't'ION TO RRL EA F,j,_ ORMATIQN;,when applicable,I, the owner or operator of due property locetcc at dee <br /> above site Addrdss, hereby audeorize the release of any and all results, geotechnical data and/or anvi I Isnfent <br /> Inforrmdott to the SAN JOAQUIN COUNTY ENvittoNMCfrTAL HSALTH 135PARIMENT as sow as It is avaitatTl� r tc it is <br /> provided to me or my representative. REC <br /> TYPE of SERVICE REQu£S w vzq�'\Q/ �t P��,t�< , &c�Cr ntn i� <br /> { CopgEMTS: <br /> SANJOA IUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> /APPROVED BY: EMPLOYEl9S. a� DATE: o <br /> ASIOGNED TO' EMPLIDTC4 d: ���LS \ DATi: <br /> Date Scrvieti Completed (it.traady eomptatadyt Se1mmcool! \�'.� <br /> fee Amount, Amount Paid �a� payment DAW <br /> Payment Type tnvoiae p3 CHeok S t p(o Received By: �- <br /> SRD d-5.02 025 <br /> QEVI&Fp A SERVIt iS REQUE:31 FORM <br /> REV <br />