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FROM :Donlee pump co. • FAX NO. :2095379398 0c. 03 2004 10:02AM P2 <br />SAN.IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REOC7E,ST <br />Typed Bushaux or Property <br />Ord Eda_lson CHICK 0BlllxaAmm[3 <br />11119UEW NAME +�'✓nI - <br />FACWTYID# <br />8ER=RBQUE.aT# <br />FAT#env �y <br />1 1 3STATE <br />�n <br />��>r�� C,� <br />OWNER IO YOR R <br />/� <br />L <br />T Mahrii <br />cxEgc N eauNN AeaaF3i6 <br />FAM" NAME <br />. , n <br />str�ADnaeaa 2K <br />Stockfbn-Nr-cc <br />Rlx*i <br />jqo3b� <br />s m <br />n cee` <br />Hannor MALWAODRCss (N mwahantimm aa. Address) <br />CR <br />ftM1NvWbJ <br />STAT# LP <br />Plaval1 <br />g*• <br />APN9 <br />LAse USE APPLIOAr4N0 <br />(200 5qq--371C) <br />Alal!#i-1 FAQ —N,-59 <br />ea. <br />BOER laslprr LOGTa1N O0n! <br />CONTRACTOR/ SERVICE RE0ITlP.STn1R <br />RtlquasTOR <br />�j�. <br />Ord Eda_lson CHICK 0BlllxaAmm[3 <br />11119UEW NAME +�'✓nI - <br />P"01418Crr. <br />�. <br />HONEorlOWM/AWREssn - a(Ir <br />G 6 <br />FAT#env �y <br />1 1 3STATE <br />4ILWLy4 ,At:15P1O`WLAl)GEMENT: 1, the hmderslped property or busbass owner, operator or aatborinsd #Bent of same, <br />t10knOWlC* t1At all she and/or project speoific ENvI➢awwTAL HBALTR DEPARTMRffhourly rJtarlies asSOClated with this project <br />or eotivity will be billed to we or my bastaess as idandfied on Chic form. <br />I also notify that I have prepared this application and that the work to be performed will be done in a000tdanae with all SAN 10AQUIN <br />COUNTY Ord%ww Corky,STATE au L UP", <br />APnJCAN r9 61GNATURE: iiYw\--�) DArc: <br />PROPERTY /BuawaMOrvNERE3 11RATOR/NIANAORII E3 0=UAUn=M0AGANTg �f'jt T-IVQ <br />If APPldCANT4WfllwB1U4vGP.utrr.proofgjau1ko?kaA nigmBnisregabrd MIN <br />AIITHOAiY.ATION TO MxT.e � OVPORMATTON: Whan applloable, 1, the owner or operator of the prcpelty located at the <br />above sNa rddress, hereby authorize the release of any and 00 Mulls, geotechnical data arhd/or anvirontnontal/slte assessment <br />ftl ftlthhlation to the SAN IOAQUtN COUNTY Bt1VIROMMAL HEALTH DEPARTNUi 1T as *nen M It is avaU �t piielaeme time It is <br />provided to am or my repreeenMtivo. �'1`���°r'' . <br />T" OF UMi-- <br />t:oaaarr. <br />DEC - 3 CUv' <br />SAN JOAQUIN g0UNTY <br />ENVIRONMENTAL <br />-I{FALTH DEPARTMENT <br />Aenq BY: �� E iP_ <br />SMR.OYiLd: L' � a / <br />DATE: <br />MRaaeorO: �--,ry. ✓-L-,.c c- Eretovjgg#: <br />i7 DAreIZ 3�n/ <br />Data BerviceCamplered(aalraatyeo); <br />Fora Amount: #rmnteCaoe: �<�� PIE <br />2 3 , c,8 <br />C l Illnannt Paid Paymaat D#b IP-Paynwrht Type tnhralq lF Cho* 0 7,ac Reeelved By. G /1 <br />F.HD a-wot# <br />REVISED 11/17/2003 <br />�� <br />ERR FORM (Oaldea Rel) <br />Ze xvd H11t+31-1-'iV1N9WNOrjN3 BEI049b 0Z:9I D00Z/6Z/IT <br />