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SERVICE REQUEST (SERVREQ) Revised 8/23/93 <br /> FAf ILITY ID k9i3 RECORD ID k J INVOICE M <br /> ZE� 384 3 <br /> ,i <br /> FACILITY NAME Stockton Metropolitan Airport - Key Lock Facilit BILLING PARTY Y / <br /> SITE ADDRESS t Snob S. -V_ —� p <br /> CITY Stockton CA ZIP 95206 ,1 niV <br /> OWNER/OPERATOR _ _Department of Aviation, County Of San Joaquin BILLING PARTY © / N <br /> DRA Stockton Metropolitan Airport - Key Lock Facilitv PHONE !1 ( 209 1468 - 4700 <br /> ADDRESS 5000 South Airport Way, Room 41202 PRONE R ( 209 ) 468— 4707) <br /> CITY Stockton STATE CA ZIP 95206 <br /> F+�APN M Land Use Application N 11 - <br /> 1`F 177-260-09 adrM <br /> CONTRACTOR aril/or <br /> SERVICE REOUESTOR BILLING PARTY Y / N <br /> DBA PHONE 01 ( ) <br /> MAILING ADDRESS FAX / ( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> DHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <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 <br /> JOAQUIN COUNTY Ordinance Code rd Standards, to and F rat laws. <br /> APPLICANT'S SIGNATURE / <br /> Dan DeAngelis <br /> Title: Airport Manager Date: Mav 13, 1994 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> anvironi,ntal/site assessment information to SAN JOAQUIN COUNTY PUBLIC HE,rAyLgTH'fNVIRONMENTAL HEALTH DIVISION as soon as <br /> It is available and at the same time it is provided to me or Ory represenifstiRY , <br /> Nature of Service Request: 0 '` tF Service Code <br /> County of San Joaquin 1. <br /> Assigned to Department of Aviation Employee R CO <br /> PUBLIc�N-1ALHVIL-1 U <br /> Date Service Completed _/ / Further Action RgcJriuw / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt / Check A Recvd By <br /> E— a <br /> RENS �/_�._._/� SUPV _/_J_ <br /> ACLT _/� UNIT CLK <br />