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02/11/2005 12:30 20949565 VALUED ENGINEER* PAGE 03 <br />SA14 JOAQVI N CO U TI Y ENiVMOr MENfT.AL Fl>rA LTH iDRP.A,RMENT <br />SERVICE REQUEST <br />type of Ru*elsg or Pmp" FACILITY ID UWCR Rio -MST # <br />�;!&Pewsj'61 <br />FACIL L <br />Suft <br />NOW or MAl1 iNG AOattE9+J (M Dlft:r nt tram tet+ nadiosa) <br />ICrrY G .1 3YAZA Z'JP 155 <br />Pltp ill tiAr, APN A Luno use Aaot a7�naret! <br />PNow Gt71i tDf.TI11CY I.aCl1PMN Otftl! <br />-- a� <br />LI <br />CONTRACTOR / SERVICE REQU.ESTOR <br />Reaue8TOR <br />Buslw <br />Hten ormmuwcAppmes Fq# <br />CITY STATE C.j4 ZrP <br />H1L_l Sk : 1, the undetltigood prop" or busiptstt *Wger, operator of authorlted agsot of wane, <br />ackaawledgc that all slit sn4for prnjeer gr40ific El tTMONMENTAt. HFAT.TR DRI. ARTM6NT hourly al,sjge5 asumaeed with this PrnjM <br />or activity will be billed to toe or ery busfiRess AS idctnified Ott. this form. <br />1 also cettify lbst 1 hive PTepR MI this application gild that the w®rk to be perfumed will br dant in actordance with ell SAN JOAQTjrN <br />C OW47Y Qrditnoncr Coates, Sfandd.-ds, ST and E <br />A"LICANT'S SAGNiA.7't7R8: <br />PRDPMTVI 9VtINVM OwrtEtl t3 OPMAIORI "AGER%- OT—IMAtrSMMYDAGaNt d <br />If APPI.PC4NTM not fire Uk►Nt F/UtT'Y: pstttrf of aatlmrizatigat tv aigw is rregjwjpe i Tr+rr <br />U 43M.4 Wbcn applicable, x, the owner or aperator of the property locatcd at the <br />above ate address, hereby authorize the .reloaaae of any and all results, gcotochoical data sad/ur envimnMcouWstt0 assesRmettt <br />information Eo the SARI JoAQt1d eotm T awIIkot4mENrAr, WA1,170 1)1SPAp'(ME?" as soots aR it is Available and At tho some time it is <br />PMvided to Mc or my renresantative. <br />TYPE or SERVICE REQUESTED: <br />Celawtxrs; <br />/4CGEPrt!DIBY: 7 <br />EMPLQYl S C-?? L! <br />DATE <br />A"N;w tlx: S It I <br />Ea/PLunEs —7 3 f'v <br />DAM: <br />DO* Sary M COMplMed nr „rtsady t o,t�t.tid); <br />SEttncECtu : i cf i� <br />P I E: Z c � <br />Foo AM ounf: � Q c� Amamnt Pald <br />Payntttait ryas rrrvolr:e a <br />a i g a lc) Mt>MgmeM! oana <br />Chaok t>E 5X33 <br />(? O S <br />RAcalved W. � <br />EHO 4$-02-035 <br />REifl$60 11/172003 <br />PAYMENT <br />RECEIVED <br />FEB 17 2005 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />,EALTH DEPARTMENT <br />99 FORM (Golden Rod) <br />C-01 L980 2S6 602 dHW d62: SO St] *PT qad <br />