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SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE # <br />SERVICE STATION <br />j <br />(707)579-0250 <br />/R�EQUEST <br />VY�i <br />(O <br />OWNER/ OPERATOR <br />NYLA PLACE <br />BILLING PARTY <br />CHCCEttVR�RNNOAANMM PRODUCTS COMPANY <br />CA ZIP 95401 <br />IFCAH�VHONESERVICE STATION <br />SITE ADDRESS <br />301 <br />W <br />KETTLEMAN LANE <br />CONTRACTORS SIGNATURE: <br />APPROVED BY: <br />Street Number <br />Direction <br />Street Name <br />�' O <br />`^ <br />Type <br />Suite# <br />Mailing Address (If Different from Site Address) <br />ady completed): <br />CHEVRON PRODUCTS COMPANY <br />PIE: <br />Fee Amount <br />CITY <br />Payment Date —( <br />STATE ZIP <br />PO BOX 5004 SAN RAMON, CA 95401 <br />Invoice # <br />PHONE #1 Ext. <br />APN # <br />LAND USE APPLICATION # <br />P25)842-9083 <br />045-140-02 <br />PHONE #2T• <br />—7BOS <br />DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR BILLING PARTY <br />MUSCO EXCAVATORS, INC. BRYAN H. MUSCO <br />BUSINESS NAME <br />PHONE# En. <br />MUSCO EXCAVATORS, INC. <br />(707)579-0250 <br />MAILING ADDRESS <br />FAX # <br />NYLA PLACE <br />(707)575-7389 <br />X21155 <br />SANTA ROSA STATE <br />CA ZIP 95401 <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 />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION houdy charges associated with this project or activitywill be billed to me or my business as identified on this font,. <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 JOAQUIN COUNTY <br />FEDERAL 18WS. <br />APPLICANT SIGNATURE:��►�� DATE: <br />PROPERTY / BUSINESS OWNER El OPERATOR/ MANAGER 11 OTHER AUTHORIZED AGENT t <br />If APPucANT is not the BJu nuG PAR rY proof of authorization to sign is required <br />Ordinance Codes, Standards, STATE and <br />7/13/98 <br />PRESIDENT <br />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 release of <br />any and all results, geotechnical data and/or environmentaUsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br />as it is available and at the same time it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTE .fl <br />UST REMOVAL <br />PAYAWnin <br />COMMENTS: <br />RECEIVE <br />JUL 15 1998 <br />JOAQUIN COLON ly <br />C HEALTH <br />ENVIRSAN <br />ON SERVICES <br />MENTAL HEALTH UIVISION <br />I <br />,NSPECTOR S SIGNATURE: <br />CONTRACTORS SIGNATURE: <br />APPROVED BY: <br />EMPLOYEE#: <br />( <br />HATE. 5° he <br />ASSIGNED TO: <br />�' O <br />`^ <br />EMPLOYEE #: <br />DATE: S x <br />V <br />Date Service Completed (if al <br />ady completed): <br />SERVICE CODE: O ^ <br />PIE: <br />Fee Amount <br />I Amount Paid <br />Payment Date —( <br />Payment Type <br />Invoice # <br />Check # <br />I Received By: <br />