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REOUESTOR i <br />riCk R i rci ,0.11rt5oll , CHECK If DUNG MORPH III <br />BUSINESS NAME PNONE 1 <br />( ) <br />Err <br />HomE or MARANO ADDRESSI /4.i <br />00-16•1,-1 Oar iiis-..)h Rd <br />FAS 0 <br />( ) <br />Cm Ace, rnpv r ;ill STATE ZP qS-dA7 <br />BILLING ACKNOWLED(;EMENT: L the undersigned property or business owner, operator or authorized agent of same. <br />acknowledge that all site anitor project specific ENVIRONMENTAL HEM TH DFPAR 11,11-N t hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />PA <br />liTAt C /L/ <br />ApR <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JoAQIN <br />0 I <br />202/ Corwry Ordttutnce Codes. Stand S. STATE and Ft ER q lAws. :181114514 <br /> DATE: 3D —at nea tr Poiwk cou <br />47;4 NrY ARrm Eivr <br />APPLICANT'S SIGNA <br />Pitortazy I Busritssihweast)X <br />Or A PPLIC,4vT iv not the pll.uNo POT) proof of authorization to sign ii required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable. I. the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, gcotechnical data and or environmental/site assessment <br />inthrmation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />OrERA TOlt MA's %C. OTHER ALTHORILLO AGENT 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D E PA RTMEN1 <br />SERVICE REQUEST <br />Typef Business or Property <br />Q5 <br />FACILITY ID X r-_,SZVO10EI: QUEST <br />' 16 b19 <br />II <br />OTER / OPERATOR i3 <br />i • I 1.-1 C.,•,' CI lc CP 1 CAI ei 5c7-v-I CHECK if Brume Arodtf $5 <br />F awn' NAME <br />Silt ADDRESS <br />V LLU3CIA. (-. 1/\ aC9 I /11s am. 4C csityrVI C_) 61i21-b <br />HOME Or MALMO ADDRESS (If DIfforant from SR. Addreifs) <br />St, re %I wr,ber SI, eV Nam. <br />CITY STATE ZIP <br />Noe I/1 . Err <br />110/ 1 5-7V -595S- <br />APR X <br />Oaloil‘S- 9 <br />LAND USE APP ,, 'CATION 0 <br />. Prow ft2 Err I 605 DRITRICT ,... 1 LOCATION COCA, ( 7 <br />( <br />CONTRACTOR / SERVICE REQUESTOR <br />TYPE or SERVICE REQUESTED: . <br />COMMIT'S <br />\— CAC t" c‘i e\c) 0 a ce ."--- 42—J (r cc, i u <br />re 1e, "Ice. Ple,lp do J-enti Te i \E ClirCI ifiCky Ci..V/ge.... lyr ephusttera <br />rvo ih tougl pperf4y ?rid if; se4e46L cAYI be me,4., tr.oce,4bm <br />h e 4. ri f rtiyie. pArs i Pe PiGiGrillePt-lf kc (t , ne /0, <br />fe seep tic,/ <br />i ateoliek <br />4 ( vsiel )S, /1) <br />1:16e y1//2 i <br />Dam /3 1/) i <br />ACCEPTED BY: ,,r•-•"--7 _,Z...„1......._ EMPLOYEE I: <br />GN ASSIED To: F jz EMPLOYEE Ell: <br />Date Service Completed (If already completed): SERMCE COOE: 04, ) ) PIE: yaw <br />Fee Amount: /5- Amount Paid Amount Paid , , V, 60 Payment Data '-- i 7f/2 / <br />Rec.. 14:4(6--- <br />Payment Typr. Invoice tt C heck <br />. /22-q 71°2Z--- <br />EHO 484)2-025 <br /> SR FORM (Golder Rod) <br />REVISED II/1112003 <br />2