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SERVICE REQUEST <br />Type of Business or Property I FACILITY 10 #SERVICE RCJ/~J c9-.~ <br />/"'7411'1 r~N~r(CE ,cAc.z;L,ry <br />OWNER I OPERATOR .BILLING PARTY 0 <br />A.4-.~.-.....:1-.J~~c.,~S7"'12 (Jc.r,o,.J <br />FACILITY NAME . <br />S?I4N05 CrOl..,c C~N~~ <br />SITE ADDRESS U 11.£i!:d I I I I~~I W.{,;Ia--Ifr Str ••tHumber Direction Stree1 Name Type Suite# <br />Mailing Address (If Different from Site Address) <br />C:=fo/34/tV.Rc hI r(H-0c>.D PJE?./I/~t.3~RRY ~VJ-I c: <br />CITY STATE ZIP6n;ck~era,Q6"Zo7 <br />PHONE#1 ExT.I APN#llANo USE APPLICATION # <br />(z,01)~/7 ~-7'7.:;;-q 99-/D <br />PHONE #2 ExT.I BOS D.lSTRICT I LOCATION CODE <br />(), <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR BILLING PARTY ~ <br />A6 -::SPI9N~.s CA-t51-vvc:f.-r'"'\c/o gR.2~Y RUH L <br />BUSINESS NAME PHONE#ExT. <br />.::5?;J r(t)$L7-CU=-O,rz (?ts1)~78-7CjS'4 <br />MAILING ADDRESS ,RobIA!?loop FAX # <br />/i3e:;/W.D,r2..(10')«rs-~703 <br />CITY ;S;to~-f.-,STATE CA.ZIp 9S?c 7 <br />BILLING ACKNOWLEDGEMENT:I.the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project specific <br />PueLic HEALTH SERVICESENVIRONMENTALHEALTri DIVISIONhouriy charges associated with this project or activrty will be billed to me or my business as iden~fied on this form. <br />I also cenify that I have prepared this application and that the WOi1<to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes.Standards,STATE and <br />FEDERAL laws./ <br />ApPliCAHTSIGNATURE:~1P!-4;;zf:DATE:"/2..~/9& <br />PROPERTY/BuSINESSOWNER C OPERATOR/MANAGER 0 OTHER AUTHORIZEDAGENT tit eNCTINEEf?. <br />If APPUCANris nottheBIWNG PARTY proof of authorization to sign is requira!-Title <br />AUTHORIZATION TO RELEASE INFORMATION:When applicable,I.the owner or operator of the property located at the above site address,hereby authorize the reiease of <br />any and all results.geotechnical data and/or environmentaVsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTALHEALTH DIVISION dS soon <br />as it is available and at the same time it is provided to me or my representative. <br />I TYPE OF SERVICE REQUESTED:~Ji;,..?1~~I/).;,"-~7 !J«~ <br />COMMENTS:PAY ENT <br />RECE Eft <br />JUN ~01998 <br />INSPECTOR'S SIGNATURE:CONTRACTOR'S SIGNATURE:i ~rrROvcD 6V:C EMPLOYEE #: <br />ASSIGNED TO:C <br />Fee Amount:{5 <br />Payment Type