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'04/0$/2009 08:33 09?51P STEPHENS-RIVPT L''11-i PAGE 03 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL H,CALTH DEPARTMENT <br /> _Ty _ SERVICE REQUEST 5T <br /> po of 8[isin4sa or i'rDperty FACmTY ID p SERVICE'REgU1ST at <br /> _ rn <br /> OWNED ERPOZA <br /> AT <br /> / Crvccn K p <br /> fWat Numbef I alrectiCft _ZIP Cole <br /> NOME e►hIMtINO ADDPM llf DlfNrant from 840 Ard►nos) <br /> Civ <br /> PF 1 sm Er'. Alii■ LAAta U26 A►rUCATY-W0 <br /> � I f <br /> PWcW c ru,. 908 D13TarT Lt)rat110++caaE <br /> cONTRACTO / SERVICE REQUESTQR <br /> Cr�t+r,'x tf��{�pteeaS r-1 <br /> BC1DiNC95 NAME �.._.._�� ._- PWGNf a,w ■.t. <br /> Ftl ou+4 0�nit uw4 �lziD9 FAA 9 <br /> etax T�� z <br /> Y STAT�M+4; -JP 9s-z6 <br /> f G W ti T; 1, tht ursdcrsigned prriperty or business evtnrlr, operator or authorized agent of same. <br /> AcknoWed2c that 1111 site and.-'Or project apstc f-c ENv1RONMLINTAt.HPALrii DPPARTM ts"r hourly cha-ges cssccldrad with this projecl <br /> or act;viry will be billed to me or my business as identified on this farm. <br /> I alto crmfl that I navc prepared thin,appli0lion ane that the work to be peribyrned will be done ,n accordance with alt`AY IpAtrtn;. <br /> Cov'r,y Orc?i)v;fcc 44�ica,5 rjrda, STAT&and FFDERAL laws. <br /> t�a'LIt:nNT'S crGn -- AAT,r.- <br /> -4--6- Q2-- <br /> PR{ti*L■t'1•?k,sIVFsFOwNpikO OrERATON/MANACrR Qrmj)%AuTHOftiziGr AGENT 1_7 _ <br /> #r•1PPL1C4Nr•is nor rhe „/,�yG P ChTF•proof of amthart2'rrrin,r to sigm it require# rifle <br /> c5 LTJrC7 IUZILMN TO REI.F,ASE INFt]ut4 A IQN3 When applicablc, i, the owner at uperntor of the property located at the <br /> ai%ove sift addraps. hereby authorise the release rf any and all result+, g:rtechniral data and/or onviroamcrtal/sitc amcvvTcnt <br /> informantm to the SAN JOAQL111-4 COUNTY Buv1RpNUFN7AL 14pAI,Tfi DEPA TVRTVT 49 soon!1b it is available at5d at the same bine ?1 i5 <br /> provided to ne or my representative. <br /> CtfMVIF}1!4' > �J� <br /> ACCEpTim BY: —'""' E}U►;.t1YQel qAr■; <br /> �1at/iCiwLD r0'. q ElY{Ri9YFE fM; ❑ATEt <br /> DeteSerYic■COmplet■d (lriitretdYcamptotatll; I SeAftsCott: <br /> FI as An,ounr.� <br /> Armou"t.Paid <br /> P■yrri'm Type �7 I o � Pa�tyrn■nt ko U Q <br /> ROC <br /> REV aEC)I . SR pdRM IGIOMn ROCI <br /> RL'IISE(]f�,�t;�rzoa3 <br /> PAYMENT <br /> RECENED <br /> APR 4 8 2449 <br /> SPENtWX) AECOUNTY <br /> FE��DEPART <br />