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FROM :BRADY ELECTRIC � FAX NO. :19163923925 Wov. 05 2003 04:30AM P1 <br /> 11/04/2003 16:23 46401 d3 ENVIRONMENTAL, HLAL,TH PAGE 01 <br /> IAX.091-N!�5 SAN JOAQUIN COUNTY ENVIRONMENTAL TrrAA T1.1.Df:PA.RTMGNT <br /> _ SERVICE REQUEST <br /> Type Of 60Uass ar Properly FACILITY 0 0 SERVICE REQUEST 4 <br /> OWNER 1 t:?PERATC3D4 J <br /> e� aHecx WAN Jf .�, 7 <br /> FACILITY DIIAtAE �C1 <br /> SITE ACUR965 <br /> �° � .•,-__---street Nu r plinflon &o <br /> HOME Or MAIL NG ADDRESS (If dtffamnt from Site AddreasD <br /> CITY STAT1a---- LIP <br /> PHON;01 EXT. APN 4 LAND TJSE APPUCA7I0N# _--— <br /> RwoN[a2 BAT. 86$DisTA1Gr LOI;ATtoxCCive <br /> t D <br /> CONTRACTOR I SERVICE REQUES'TOR <br /> + ,p C14ECK if D <br /> SUSINESS PfA1M6 PttbHE <br /> &K*. <br /> HOME tlrfAAp.INGADDRESS 7 7 ✓ � FAX <br /> 74 /� 3i)-3C -S <br /> CITY STATtd 6 4$ 7JP /5.'L .a _ <br /> I)iXLIDISr ACKNQWLFDGAMENT: x, the undersigned property or hasiness owner, operator or atrrhartzoil rtgent of st+Ttie, <br /> Acknowledgo that all site and/or project speCiftC ENVIRONMrzNYAL.TirAI.TTI DC-PARTMr-NT 11Gurly sbarges ossoaiatad with this pre icel or <br /> uclivity wlll be billed to me or my Dattsiness as identified ort this fmnt, <br /> I also certify that I have prepared this ttpplicgtion and that the work to be performed will be done in Accardtttice'Witt+ nit SAN,IC AQUIN <br /> CouNTY Ordinance Catles,,Standards,STATE and Prmf-R t.la+V4. <br /> APPLICANT'S SIGNATURE: / �'r /' t� m,_. ..,.. DATE: <br /> PI;oI'61t1'y I MI&Ntt,SA Osymrn t ttw70tt1 Ma vnCtut © Or,11n AcrrrtoltlZtsn AtArcKr Q <br /> Jf APPLI ANT is not the, �J-- d(t7y,prrr,��nf arrt/ruriantirrot to 11rie is requlrtd <br /> A11THORIZAIJON jQ RTLY&ASF IP-ORD1 xr!q_N: When applic2lik,I, the owner or operator of thq proptlrty locatec at the <br /> .hove site Address, hereby audwriae the release of any and all resents, gootechnicaI data and/or envi i tr�mc;stncnt <br /> inrormitich to the SAN JOAQUIN COUNTY ENViitoNmr-WAL NI At.TH DSPARTMEW as soot as It is availa01 t `�r r 1e it is <br /> V C <br /> provifled to me gr my representative. REC% _ <br /> TYPE OF SERvIcE f EwesTED, 1 V-- <br /> COetHI:MTS: _ <br /> SAN JOAQUIN COUNV <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: I MALOYEF M, � �tSt_ DATE: 5 'V ... <br /> ASSIGNED TG: EtNPLOY` #: �5=�5°1 DATE: <br /> Pate Setviet Completed (if slrsydy vomplelad): StattVtOECOOT! P!E: <br /> Pee Arnount! ��� — Amawnt Paid t} Payment(sato <br /> Payment Type Invoice# �'2S3GK&OX tC Gob Roasived By: <br /> JEHO 4&01-025 SEAVIdIt.REQUE31 FORM <br /> REV18Fr7 6-5.02 <br />