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JUN 06 2000 7:11AM LASERJET 3200 p.2 <br />`138/16/2005 09:81 2894693433 II EHD PAGE '01 <br />SAN JOAQUIN COTINTY EfgVl ONMENTAL HEALTIi DEPARTMENT <br />SERVWE REOUEST ' <br />Type of dvalnees or Property FACIlJ1Y ID / 12010E MQUE9 N <br />r 610 OS' <br />OwrriR/ E <br />' Cntcnfr � � a <br />FACwrr NA <br />G�—L-� �. <br />Asst <br />t <br />ki <br />HOME or MAIUNG ADOAEtt (it Diftfsnl hin, $NO Addis") <br />i <br />clr7 a +' ZiPp <br />i 9TATr <br />PeckEttl �. Mb.A ' I.woU:cMr►toAnowe <br />FNOIR110006 Dllill{I01 Locum CAD <br />CONTRA.CrOR S <br />VICE• REQUESTOR <br />rtaouEarOAw�( <br />1 '. �1 S <br />I ONeur If Jap dQEpi t.,a <br />8U91NEa.1 N Mi <br />PHOMeN <br />mom r MAIL fN ADDRESS <br />K <br />CtT7,C-yrCC-k— 776 6 <br />STATa�(�� Zi / <br />BIL LING ACIQJOW s'n0ZNfZNt: 1, the undersigned pr <br />porty or busiatss owner, operator or aulboria►d attnt of some, <br />acknowledge Ihot all site and/or ptuject specific ENVIRof hmr <br />)tEALTH DOAAistlQl►T hourly chargee tuseclated with this p►ojeol <br />of activity will it billed ro me or my business as 164atillad on 1 <br />Ie fbrm <br />13110 oCAlty that I haw prepared t ' c told that the* <br />ck to be ye►fgrmad will be dont in accordance; with 1111 SAN )OAQUIN <br />COUNTY Ordleonce Cods, ardt, TA ate F2DVtA& <br />). liw <br />APPLICANT'S SI(ATtI <br />Dn7�: -7 <br />teotTRTYIhAthT."OWN6a 0 'RA It/ AeAGt110 <br />� 0uiuAurvoaueDAeet+rC1 <br />!J,llf1K4NT 1S hof rhe 1.t g k7t proo/Oj0�f4bnrflo(lpn <br />to dijll it rtquved rase <br />AU I" R12ATION TO AES, ASS, E t A 7 : W <br />, <br />i applJoible, t, the owner or operator of the preptny located at the <br />Glove site address, horeby aud►oriza The release of any and <br />•1) ru48a, 6aotochnioal data And/or ervironnuAtWake wositnum <br />informulon to the SAN 10AQUIN COUNTY E14N1JtDNMUr0ALk:1EAl,Tli <br />DEtARTMmT is soon at it is ovallab1Q And at the reale tinrc It is <br />ptcwidcd to me or my ►tpreaantalivc. <br />TTae of Somew REQUESTED: <br />REdbE <br />9aeeern; <br />JUN 0 8 2007 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />s- FAITH TMENT <br />AcccrTepgr: EMpIoyoxf: p CAT[: <br />Aa>roh t0 T0: ' � ,ENrLOrI:I:Irt r 0►tE: <br />Doty service Completed lir ■Neasy eompteaed): lillvttx CooE: P Is- <br />Fee Amount Z n LM <br />Amount Pod va�S ; Payment Ate <br />Payment Typo MvolcrN 11 Check )r �3��� Rec•ivo Sys <br />cHD 4e-0soss <br />REVISED 1 onvzoo3 I; <br />j <br />1 <br />I <br />ISR r9RM (Golden MCI) <br />