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tla�3 15 2012 5:59PM LASERJET FAX 20 46-8099 <br />03/08/2011 09:30 2994640138 ENVIRMWNTAL HEALTH <br />SAN JOAQUIN COUNTY )h,NVIRONML NTAL HEALTH D$F'ARTMWT <br />�SEE�WICE REQUEST <br />Type of 9wlneis or Property YACILITY 0 + SERVICE RN <br />OWNER I OPERATOR �• <br />FACILITYNAME <br />bi'l'e AGGRESS <br />4091 of MAL K3 ADDR128 jif awarent from Slto Addiv, <br />Ikir <br />c1Yv -- <br />PHONtifl E>,r, APtoo <br />PNCNI 02 <br />z-�Ct6 <br />CnBcKif BILL <br />STATE 21P <br />LANG Uft APP+uCAMN 0 <br />4 <br />p.2 <br />PAGE 0109 <br />I I 1� Boa DISTRICT � LocA17ONCOQR f <br />,CONTRACTOR I SERVICE REQUESTOR 11 <br />RevuesTOR � <br />_ <br />0119cif If BllQg Augnm <br />Bualwesc NAME � ' �+1, 4 A <br />_ a It iI <br />MeAt <br />faoMcorM�I�rHoAoopt O1�, 7 FAX <br />CrT1' _ SYATE Zlr <br />IM L1r1f; A N .WLEDGEMENT! I, the and-tnlgoed prnperry pe baNnvrs owner, opermtnir or Authorized went of eamo, <br />acknowladge that all s(te and/or project ppeelflo ENY]RONMY.NrAL FFA 1,T11 grpARTmLN'r hourly,cllarges ua,snt:latod w(lh (his pr .iml. <br />or s.Cdvlty will bb blllod to me or MY buAlne,e AS id,�ntlfic(I on this form. <br />I &ISO Certify thin I huve prgmcd this appacntlon and that: III owork to be performed will bo dopa in 40001`4ence -1111 all SAN JOAQLA14 <br />COUN'rr Ordi+tarted C,'nday, 51(?mdavdf, STATE and Pi3gglWl. ltiwt. j <br />APPIACANT S SLGNATUAV: +'rid <br />PPO",-y'IbmNt$xOw-vxKC 0KIRATORIAfANACtR h,IrNTO_ <br />/f.'II'l,LjC1VrJ.r not ilia l N pia,s�'nfn,rlGnrfrrma► ru titr,T l6 re <br />grifre I Tyle <br />A0210 14ATfON TO REL EASE INRORMAI10N W-hcn applicable, I. the maer or oporn for of tlw property located of tltc <br />Olive rata address, hoteby authorize the relemb of We 1116 all mu(4, gdowhnloal data and/or envImnmentAl/sM eieaasment <br />1n1'0rm4on W the SnN .IOAOInn CouttTY EI'7y1RpNMCNi01,I, f 18AUn DEPARTNIUNT at soon w it ie avnllaWo and m tllo is= time it is <br />prevldod co me or my renrawmilve. <br />TYPE OP SEAVICE RECIUSUED: <br />' <br />1 <br />L} <br />Coalydenryl J`' ' <br />AccEPTEO 13Y: '�— l uJ <br />EMPLOYEE K: q0—IS <br />DITfl; -�S Z <br />ASSIGNED r0, r <br />iMFLQYur. <br />hoe; <br />Dat« Sorvle• Comploted (11almadyaomp1mad): <br />SetvxeCo� C% <br />Flo: <br />Fee Amount; ul Amount PAI&I <br />---- <br />S Paymont Lkue <br />-1yrnent Type invoice AI <br />Check M <br />ttec0lvudByT <br />LIM0 45•0-02$ <br />REVISED 1111712007 <br />a <br />BPI <br />BR PORAL (paldem Rod) <br />PAYMENT <br />RECEIVED <br />MAY 2 2 2012 <br />SAN JOAC)UIN COUNTY <br />HST} -1 DEPARNTNIENT <br />