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FROM :BRADY ELECTRIC FAX NO. :19163923925 ov. 05 2003 04:30AM P1 <br /> 11/04/2003 16:23 464 EWIRONMENTAL HLALTH PAGE 01 <br /> M"'WilV%-!Mb5 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH.DEPARTMENT <br /> S)ER'VICC REQUEST <br /> Type or Hutlness or property FACILITY ID ID — <br /> -��C1G f � �' YiCE RI?:QUEST� <br /> ` � <br /> OWNER I OPERATOR p •WAWM <br /> J +�G 0L-� t; crcKly, ; <br /> S1TE AVOWS ---, <br /> _ Lo e-k-finr' - ,f- Le)d i JS`� W <br /> HOME Of MAILING ADMI111 (M Olftewr I from lite Ad*vsi;) <br /> $Tare zip <br /> PHON:01 LAN®Uff AP"Amon« <br /> PNDNI tt2 ®AT. Qt`}�iA$TRMf t Wrio 90 <br /> CONTRACTOR 1 SERVICE Q STo R <br /> REauesro -•- , <br /> l / G �° CNccx if <br /> SUsav6$8 NAME PHONE I <br /> i-icy) 'I'i7 <br /> HOW-or MALINB ADDRESS FAX I <br /> 39 <br /> CITY , <br /> STATE 6 4' <br /> K' ENT: x, the undersigned property or burinoat owner, operator or anthertzaid nput of same, <br /> ACkteowiedge that all site and/or project specific ENVIRONMENTAL 1iFAimi DEPARTMENThourly charges apsmislod with this ptt icct or <br /> activity will be billed to me of ray business as identified on this form. <br /> I aiso:certity that I 112ve prepared tilts application and that the work to be performed will be done in accordance with all SAWIC AQUIN <br /> COUNTY Onfinance Coda,Sitrredards,STATS and PenrRAt.laws. <br /> APPLICMT`SSIGNATURZ- /�'i7�dn / .�^'L RATE- <br /> PRerCRTY/BlImmKaadwrsem>: s"ttIMA;eA(;= ® Or1 <br /> 1 <br /> enAtmi0itltanAur.N E3 <br /> if.I r'PLt!AA+f s n0! {r`r proof of autb®rixattoot to dgit kr required rate <br /> AU f•[ ORIZA lab!T,, HKI&WE 1. -Q.RMAT10N-.,When ttMliesble,1,the owner or operator of aro proporty laeatee at tim <br /> above site Address, hem by authorize the release of any and all results, zootechnical data and/or envi 1 isment <br /> Intbrmatiott to the SAN JOAQUIN COUNTY ENviRoNMFN`TAL H2ALTH DISPAR-MENT as soon at It is availsol EGt� r x it is <br /> provided to Ura gr my reprceentative• <br /> TYPE OF SERVICE RMMTEW. \@NJ,Gy. <br /> i CONpEMTS: <br /> SAN JOACQUIN COUNTY <br /> ENVIRONMENTAL_ <br /> HEALTH DEPARTMENT <br /> APPROVED BY, EMPLOYEE III: �j�"Jam" DATA' V c)® <br /> r <br /> A8m4NE01b' E PLOTer4: <br /> Date Service Cornploted (if already completed), St+RAWCON. Vzk% P.!E: � <br /> Fee Amount: Amount Paidpayment Data <br /> Payment Type Invotcm S �' 3 Ct <br /> OR S L®to Received By: - <br /> Ewe 49-01-025 <br /> REVISBQ 0 d-5.0-5.0 2 SCRVICII Rr!Quis.r FORM <br />