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[RI &'4[EDarl W. Thompson, Jr. <br />u <br />JUL 0 8 2009 <br />ENVIRONMENT HEALTH <br />PE UMFRVERS <br />209-4786064 p.1 <br />SAN JOAQUT?1 COUNTY ENV ;.ROTMENTALECALTH DEF.413T%lF.NT <br />SERVICE REQUEST <br />TypeofBusinessprProperty <br />t E; <br />SSP.vKscDae: <br />FAtILiiYIA <br />SERVICEREQUEST# <br />05 — I Payment bete I p <br />U 1 <br />/�- • o002a� <br />S <br />�... <br />OWNER OPERATOR <br />cxeexaBILL vcADDRESS ❑ <br />NAME e e7 y <br />�� <br />SITE AnnRESS <br />$ITEAOERE55 <br />27/7 <br />/t����(�s—� <br />G 7 �Cc� <br />a1 etNu Cer <br />on <br />trout N�s-t�er� <br />c <br />HOME Or MAIM ADDRESS iIf Differentfron <br />Site Address} <br />/9j9 „� ,,� eSc,1Z:;- <br />ShS�t NT�mber !mN Neme <br />carr cS�� / �✓ <br />Cs}� 9'S20 <br />PHON01 Ems• <br />APN 9 <br />LANG Use APPLICAnON }i <br />PHCNE#2 dT <br />I 1 <br />906 DISTrICT <br />- LonaTION 000E <br />CONTR4CTORISERVICE REOT:ESTOR <br />REQUESTOR <br />crecK If AjkNG Arj R <br />HUSINESs NAMEPKMIc tIT <br />7 Wcok14,osUs,t (:;�v✓p /, /c- E r2n4 9S/s7)wq I <br />Home or <br />STATE <br />OG <br />BILLING ACTLNOWLE6GLMENT: 7, L. a undersigned property or Duciness oweer. operator or authorized agent of same, <br />anknowledge Ihai all site andlor projot! Specific $NP.RONmENTAL HcALTN CFPAP•TMLN'r houriy charges associated •xi tS this project <br />or activiry vAH be billed to me or my business as identified on this `.orm. . <br />I also cartif• that I have prepared this applicatior, and the e work to be perfermcd will be fore In acxrdrrce pith all SAN XIAO!31% <br />COUNTY On dance Cod&, Stanc7m'dr. S'a. d iEt R.a:. •.vs. <br />APPLICANT'SSIGNATURF.: <br />?1113PQIM' Ht151MAS QW,NF M i)ee12Ar'ORi 1fAN.\G1:,_(,JVi'F{Ck 1t!Tii nAl7.aD AGGM' �� <br />]f,1PPL,L•A yr 7a not the RaryNa PA.R71f proo Oq�r• ou'thOrizagon Cosign 1s required 7rr:e \ <br />AI"I'IfOR17�A'FIOf[•�'O FR__ L�FASL' 1VFORN'TATION: tVhto, applicable, le the owner cr operator of the prnper s a\ e <br />above site address, hereby authorize the release c. any and all restdt3, a otec,:nical data and'ur dnvtrorrur0gt P t���ppp <br />informatlon to the SAN JOAQUiN r'.ouNTV &1VTRON'DfF.N"AT.'R tLH DFPARTkfF.NT as soon ns 'I. is avallah?e <br />provided to hie or my tepresrootaliwe. <br />TYP"c OF SERPCE REQUESTED: <br />9S -t --/0o3 _ <br />AorePrm" <br />JUL 10 2009 <br />AssiGN¢n To: n 2C�� <br />Date Service Compls_ !;f alra::v; :or..;:exe;: <br />t E; <br />SSP.vKscDae: <br />Fee Amount: od Amount Paid <br />05 — I Payment bete I p <br />U 1 <br />Payment Type invoice # <br />Cheek t! 2 b <br />Received By: <br />E}i0 QE•02-026 <br />REVISED 11117l2c0.1 <br />SRFORU (Golden Rod) <br />