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MAR-23-2009 02:54P FROM:WILKEYS CONSTRUCTION 9166551026 TO:12094729584 P.2/8 <br /> SAN SOAQ64 COUNTY ENV11t0MW . TAI.19 ALTA ftPARTM 14T <br /> SM'VICE REQUEST <br /> Type of Btahm or Prop" FACPJrf 10 N SlERVICE RMUM 0 <br /> GAS DISPF-NS)NG -FAG LI r/ S `..5(200 73 <br /> 1\JASS,_7-AAB1�i-.� K <br /> FAaurrNANE <br /> LA Tiq v ten. Suac <br /> Slr�AuoKEss J <br /> 'JSi 7o i HA 1-(A� tL D L A TTL op 953 31 <br /> 5700 <br /> HONEurMUMAoMO (WMft » fMM8kaAWnM) <br /> 0.x S: y <br /> crrtr S TDC,1C�1�1 Sa,►�E apC-A 93 <br /> �q <br /> PkGNEtt �► APK9 Cwr DUwA"LJrAV1 * <br /> (209) Lf03-3859 1. <br /> Xnos OW aes ).oG,n can <br /> CONTRACTOR t SERVICE REQUENT R <br /> Iicatjlr FOR <br /> i S INe ;So r • UMMAMME] <br /> BUMMUNAME I _ PHOW# . ea. <br /> - 6t <br /> How or bUiu ie ADDREssoh 7( iib - t <br /> lea: 6Fb�, S7AW CA ZfP <br /> -I.the uade:nigaed propartY or boWnws owner,operator or authorized agent of wase, <br /> acknowledge dwi all site and/or prgl=t speaWk ElivAtotfOMMI.F&UM DEPAM MOU bAUrly eAarges aasoetated witU this Wged <br /> or activity w11 be billed to moor mar biamm as identified on tMz form. <br /> I also C"ry that r have ptWftV4 tbiia apWiedion and d mttk work tube pahmed wit be dam bi aoeordarteevdik all SAU JoAQuur <br /> COUNry t7Y&WM Cia&6 Slbada►d:.STAM qd FWMAL laws. f <br /> APPLICAMM SIGNATUttL: MA= <br /> Pa0sEaWj3V3rrMW0Www1 0MMU ttMAnAr=g OMRAVnwaawAcanrd <br /> tj PLC,AM it Aar fire&unvc to t <br /> VF04 to 999 is►rrgarfred rtrte ,� <br /> ,A�LP!'EMATiOIrY 1O RSI. IE AVfeORMATION:When appliabk i.fto mar or opesatw of'& pro" <br /> above aft* address, her by wthMiae the release Of Mayr Mad all resaI%meal data•sadfor esvicem� ant <br /> inibmwflon to the SAN JoAQU[N POUWV Brtvtl¢cN MrAL HEAL7H DFPAR7hMT as soon as it is-available-and at the <br /> provide4 m we or my ropmeatitive. <br /> CauEnra REntiEST>�: d it S'T" 1 ,W [ t SAN JORO� EN <br /> V �No 5 s`7 v Ca F'a� 11ze <br /> Pj sVev- to bp v�STwt,� <br /> C <br /> AocopM Br- L,c v F c rP—�4 Gifttwa 0 2, DAA: 3 o <br /> ASSrDnMTW. a4W. 3 2s o <br /> Oat.Servlet Completed (E *anPraddr C Spatt:FtbtA~ (9f" P FE: 2�D <br /> FaaAAraunt: Cir d� ArnowtPaid 3 l c� — 312-510 <br /> =PaynantTyp j Mvotee# Check t: Radlvrrd By: <br /> EHC�eoz Dale Adams Supervisor FORM(Golden <br /> r2 H p vow twmum r<oo) <br /> 2. d ,3 eamhuctirn .enc. <br /> General Contracting/Service Station <br /> Adamsgras@aol.com <br /> 4827 Pacific Ave NV License No. 58297/66488 <br /> Pleasant Grove,CA.95668 CA License No.722945 <br /> Office No:(916)655-1018 Fax No:(916)655-1026 <br /> Cell No:(530)682-9682 <br />