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FROM : MCK I NLEY
<br />PHONE NO. : 8355156 May. 27 2011 12: 52PM P2
<br />I,.
<br />- miEir
<br />SAN JOAQUIN COUNTY EMIR° AL, UEALTh DEPARTMENT
<br />SERVICE REQUEST
<br />Ire 01 %WM,. or Property
<br />frPORTM Et _ .14 ,1)(,
<br />FACILIN MI
<br />2- '1 c I
<br />SERVICE REQUEST #
<br />-5,C 1)0 61 2.4 31
<br />OWNER l OPIRATOR
<br />r I al 1. F :I; If #0 I „„ I • i .., 0 --66q cmeacIffisaaectagnO
<br />FnT "lc -t-/ ntey maY\o‘t iqpar-,1-71itervf -S
<br />1 women
<br />Wit or MAILIK6 Moms or casrassefreel
<br />65_se a al-
<br />c_y_ $44...l; _t:, TOlitc y tv
<br />au Addison 1
<br />ec — 40 t 1 ,I ph.o....A. /-M-LOYikt I) pi,„,. sa're 1 ciy iqc-illillcA1-7-V /3', :17 1,!1'_ nod r ecT.
<br />(g0q) 83 5 -5 i5..0
<br />ww
<br /> 5 ,,,23-(76--- c2/
<br />We Use ArtItscAroN 01
<br />9 /14--C1-77
<br />BOS arriecT I Locarol coon
<br />ONTRACTOR / SERVICE RE UESTOR
<br />' REOUEETOR
<br />%OP ,
<br />, CPM1figf 144$4,40019in
<br />Sumo* ltitim-7),1 , /, )74lt, lie: Zir I ff -5 5 — •S 75 Annitmg ,r,0 74-5.2,0-x-e-- -411 i 7 OAS ) e35 —5./4(7
<br />Crry c..ailLifie-rp 1 ISTAW 70 cl,c_c_3-7
<br />1, the Widersiciod property or bossism owner, eperator or *at:hi:whale, agent of aame.
<br />acknowledge that all site tedfcr project specific EVARONMENTAL HEALTH DEPARTMEPer boarty charges associated with this prOject
<br />or sotii,ity will be bilkid to sae Qr ray bnainaua as identifiett on this form
<br />I also certify that I have prepared this applicsaket and that the weak to ha perfbrmed will be done in actxtrithrice with all SAN ionqtrrt
<br />CtxmiTY Ordinal.= Code.s, Stindards, i and MT/MAL s.
<br />APPLICANVS S1GNATVRE: ae. DATE;
<br />NornirYi Stasnas Cho= osita.Atoa/ ALAMO= OrStak Amman+ Amer E3
<br />tf.4PPLIC 713 not the B17.1.a2PARry proof editchanurkm to lip is mitred Title
<br />Aailaratinati-M-RELEMEMENnant: When efldieabk,1, the weer or oPender of the PrePert7 1oetitg4 slt the
<br />abgve ,It. whims, hereby authorize the release of at and 40 I result% gratecimical data medlar crivironnientalisite nuereicovatt
<br />;Artemisia* to the SAw kmotraq COUNTY EmelltOWENTAL HF_ALTH DEPASMANT es soon ss it is ewes-table and at th tease titre it is
<br />proVided to me cc my representative. PAY M ENT
<br />!We OF Emma Reauarer RCE.1 V LL)
<br />‘ ccumor v6_,,e /II • i ' i MAY 3 1 21311---
<br />SAN JOAQUIN COUNTY
<br />ENVIRONMENTAI_
<br />HEALTH DEPARTIOL NT
<br />Armors° Sr Ccww.,...0—y-.... iliPLOYEE 6% 0 v.- 6, ?____ s--- 31 - 1(
<br />Assasectior, edytt zv1 /4...., blaming I-. 6, 7_,. ( Dam c--- 3 1 - 1 1
<br />DRS SIKV14/ COmpiillid (Wsinrady aorisslotad): Sin Cam: -L-2_ ce P IE: • c
<br />FsoAitiount :,), 44; , Amount Paid 1 2(1 (4, . co Psyniesst Dario 31 ) I
<br />Payment Type Invoke • Cloak • / 0 2_/ ROONVid
<br />3-/3-7A
<br />SICAPDP
<br />SSD 44.2o245, sfi Fotatt (Ookton Rol)
<br />on ;mum • , 4.vflrYfl
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