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SERVICE REQUEST Type of Business or Property COMMENTS: BI LNG PARTY ❑ FACILITY ID # S RV � VSStO"H SPUBLIO SERV E REQUEST # BUSINESS NAME PHONE # \15J5 A. Teichert & Son, Inc. APPROVED BY: Construction 386-3716 MAILING ADDRESS ASSIGNED TO: t'1 FAX # EMPLOYEE#:. wMERI OPERATOR Data Service Completed (ff already completed): (91)6_386-1256 SERVCECODE - 0 BILLING PARTY ❑ . Teichert & Son, Inc. Payment Date Payment Type Invoice # FACILITY NAME Received By: A. Teichert & Son Inc. SITE ADDRESS 103 se..Nu Nmod.e E Street su.sxam. THP. sva.a Mailing Address (If Different from Site Address) P.O. Box 15002 CRY STATE ZIP Sacramento CA 95851 PHONE#1 eT APN# LANG USE APPLICATION# (M) 386-3716 153-180-1 PHONE #2 BOB DISTRICT - LOCATION Code, CONTRACTOR I SERVICE REQUESTOR REQUESTOR COMMENTS: BI LNG PARTY ❑ George Takemori S RV � VSStO"H SPUBLIO BUSINESS NAME PHONE # to* A. Teichert & Son, Inc. APPROVED BY: 91 386-3716 MAILING ADDRESS ASSIGNED TO: t'1 FAX # EMPLOYEE#:. P.O. Box 15002 Data Service Completed (ff already completed): (91)6_386-1256 SERVCECODE - 0 (i�aycramento STATE CA LP 95851 BILLING ACKNOWLEDGEMENT: 1. the Undersigned property or business owner, operator or authorized agent of same, acknowledge TO at alts andfor project specific PUBLIC HEALTH SERwCEs ENvIRONMEnrAL HEALTH DMsm hourly charges associated with the project or arsvty will he billed tD me or my business as identified on ft torrlL also certdy that I have prepared this application and that the work to be performed will be dam in ac=dance with all SAN JOACNIN COUNTY Ordinance Codes, Standards, STATE and IDELTL IaWs. /y///) APPLICANT SIGNATURE: /!/C��'L I X /Y/L /l i. -C DATE 10-3-00 U PROPERTY /BUSINESS OWNER lx OPERATOR /MANAGER ❑ OTHER ALmiOR®AGENT ❑ Project Manager IIAPPt Wis mr ar B, I DPAan. prod cfwtlrwfddoe to sites moused Title AUTHORIZATION TO RELEASE INFORMATION: When applicable. I, the owns a operator of the Property located at the above ate address, hereby autwrae the release of any and all results, geotechnical data an Uor emrironmenmYsite assessment information to the SAN JCAoutN COUNTY PUBLIC HEALTH SERVICES ENvwONMEKTrMSION as soon as it isavailable and at the same true it is provided to me a my represents&& TYPE OF SERVICE REQUESTED: UST Removal COMMENTS: S RV � VSStO"H SPUBLIO NEOALLN HEALTH 0 ENVIPONMENIAL INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: APPROVED BY: EMPLOY#: b DATE: ASSIGNED TO: t'1 EMPLOYEE#:. DATE Data Service Completed (ff already completed): SERVCECODE - 0 'P l E: � 3d 'ee Amount Amount Paid �, i — Payment Date Payment Type Invoice # Check # Received By: 11