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' Nuv 04 05 12:10p Plan} Engineering 468-47. p.2 <br />11Uv Ua cUUU lU: uehn L.r15LKJL I JeUU p, J <br />88/1W2005 09:01 2094683433 EFID PAGE el <br />SAr4 JOAQVm Courm ElmitommN rAi, HEALTH DEPARTMENT <br />SERYXCZ REOUEST <br />Type of NuAmm a Propwty <br />FACLITY 10 ti <br />SERVICE R�Ey/CUEv��//T� 1f <br />Ccaaewrs: <br />OP'ERAT'OR <br />Er+M.ovnek 3 — <br />out: <br />' Yri <br />� t <br />'arse u <br />lsa�a,TTttAtE��-o�.ra�.�r� <br />Go�� ��A�l,r — �CJ�►•� <br />GC�r <br />o� Y.[ , <br />M Ic.b�if�- CA r IU5 r -r o <br />cit f P Sz3' / <br />2000 <br />Paymaet Typo ✓ invoke N <br />Chemo 0 11 1 <br />HoW or M AIUKAD KIN M ons mrd fleet ok• Mdmse) <br />coy <br />STAY* <br />zip <br />Protfll <br />APt1 { UWe Vai Ao"aTloH r <br />hct4 #2 ctr. <br />WS dtt:9ticT <br />10"'rim Coot <br />t CONTRACTOR / SERVICE-REQUESTOR <br />REOUESToR <br />S grErxHOatvro Aaoatse <br />Bua1NCt! E pHoaEsi lin. <br />.t S oN Com. $3 <br />rVFu R <br />CRY <br />plUMI AMLgM3j gMENT: I, the undersigned Property or buststrs owner, operator or autborned aMt o/ same, <br />acbwwkdge dim all site afWar pw wt specific ENVUtONWSrAL 1%%LTH DUAKIEWM T bourb chudea sssoc{aQ with this project <br />or aetivily will be bUkd to me or my bwlaas its Ida rifled oo this farm <br />Iso cotfly that I hays propued this applkwim and that tho woA to fu performed will be 4mc In accordance with all SAN JOAQUfN <br />Ty Adlnvnce Codes, srondmdr, 3'rATE atd 6ewotAl, laws. <br />PLICAXrS SICNATV1tE: Z/ f;Yj� _ Dolt: /� <br />PaornTy/SY'w'YatOwxct0 0v%:L%ToxJ?&KAGLa tiletsaAVt7e?a MAGMC3 <br />IfgriuGNT fs nol At p1,U1maPAR7! proof of aaN,orWaa to Qx h rsrktd <br />AMQ;UZAT{OH TO RjASX 1;VP+ljj MMM :Whom applimWie, I, the ows.or or operator of the property lowed r the <br />above sips address, baeby tied mlv the Taiease of My and all rauki , aeotecWcal data andror environrnr Wshe asses3roeal <br />irfformstlon 10 the SAN)04QM C1DVM j!XMOHkMKAL 1U'ALTH 0DARTM@tT U loop Of 11 is available and m Me tame tiD= it Is <br />nmviAM to nip nr my rem. mwative. <br />TY►i cr Srxvlce ttsauestio: l f <br />ST.• <br />Ccaaewrs: <br />Aoc>vymBr. i f L,C.( rt <br />Er+M.ovnek 3 — <br />out: <br />Aae+orepTo: <br />Empwya 11: Lrr S _3 <br />04n: <br />Date swvicacomPloted 01Akaayco"+ptw4r <br />ScM+eeCOoti: C g <br />PfE: z .c'' <br />Fre Amount: Z7 , CU AmowA Paid <br />21c). G <br />Peytaant Rate <br />Paymaet Typo ✓ invoke N <br />Chemo 0 11 1 <br />Re caivod thy: <br />eHD 4"2-M <br />REN48ED t 1117f2M <br />J <br />SA FORM (Golden Rod) <br />PAYMENT <br />RECEIVED <br />NOV 7 2005 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />