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• ..• .w `. ��.-, i 1 RVII Y. G <br /> SERVICE REOUEST (EM 00 61) Revised SIZ303 <br /> FFLIL ITT 10 Y ^ �f RECCRD i0I0 1. y�1 /1"7 O EJECIF-MT17 " <br /> N <br /> FACILITY NAME New Dow'-p i E(ew��N \�`�t / l.� ! O JUL y %-1 1 PARTY Y- / �1 <br /> 511E ADDRESS ��I�t O U (`� 1/3. SAN JOAQUUIN COUNTY <br /> -MlIMMEALTH SERVICES <br /> p E 41RONMENTAL HEALTH DIVISION <br /> C17Y �,lL��{Iu..�+��`(P���,t C�j �(�C1A` ZIP � �� <br /> O)NER/OPERAIDR �I�t�'�" �l^ 04AI�, d ;dI y/'' 7�• KILLING PAR TT � / R <br /> DBA N� �A-I,+r'7(� 'c�J� _ PHONE Ni ( i�l�/ ) •�i�-E'"� <br /> ADDRESS •!� •. " ✓"� /n G PHONE N2 L ) <br /> CITY /V,I��vL11,1.�A STATE ��" _ ZIP 1 <br /> APN Y Land Use AMI icst On N <br /> — B09 Dlst Location Coda <br /> CONTRACTOR Wd/ar ( L%p A B1l LING PARTY Y / N1 <br /> SERVICE REOUESTOR > l.(J l./ <br /> CBA �t (�`{�' PHCm N1 C <br /> MAILING ADI)RESS 211 S4 ' /� vp, VAX 9 t ) <br /> CITY t -,k e ��O STATE ` ZIP /��J <br /> sitting ACKNOWLEDGEMENT: 1, the Urderigted owner, operator or agent of save. ackaowledge that all site and/or project specific <br /> PNS/ERD hourly charges associated with this focillly or activity will be baled to the party identified as the BILLING PARTY On <br /> page 1 of this torn. <br /> 1 also certify that 1 have preper this Application and that the work to be pertoraed will be done in accordance with all SAN <br /> AGAWIN COUNTY OT'dinOnCt Godes 96 Stmidaroo. State and federal laws. <br /> l!� <br /> APPLICANT'S SIGNATURE n <br /> title- <br /> Date: <br /> WTNDRIUt10N TO RELEASE dMYODGTMINI In mWitlon to the above, when applicable, 1, the owner, operator or agent of Salle, of <br /> the property Located at the above site address hereby authorize the release of anY afd sit results, geotechnical data and/or <br /> e irw ntal/site asiecsment infonrwtim to SAN JDACUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soar as <br /> it Is ovnilsbee and at the sane time it is provided to me or mV represenrattve• ,, - <br /> Assigned to <br /> rr <br /> Service Gude O�Y <br /> Naturc of Service Request:. <br /> c-�'+F--. , 1 f` Erptoyee N - r73 Date _J <br /> T��-� <br /> Dale GKVI:a Canploted /�--/ <br /> further ACttm Required: T j N PRDORAM ELEMENT <br /> 1Ffee Arcrxlnt Amount Paid Date of Payaiett Peyetettt Type Receipt N Cheek N Recvd BY <br /> q� �o ���� -7 9 tel,~ �� <br /> P'02 <br /> 07-07-1997 09:56AM <br />