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SERVICE REQUEST <br /> Type of Business or Property 7—[FACILITY ID# SERVICE REQUEST# <br /> &a$oline D6 rroi Pacili+y 00 ��� o n qq5 <br /> OWNER/OPERATOR BILLING PARTY <br /> ircle. k Si'om- , Inc • (p0.5cP4 52084 , Phenix , A-Z 85072-2n64 .0m; .env. Ccm e, <br /> FACIIJTY NAME, I �> <br /> Facllik 4-40cl C '0S4,43 <br /> SITE ADDRESS N' ElpOraG10 ` . <br /> 15b2. se.r xwne. oo-.soe Ana nmr TY s�a.e <br /> Mailing Address (If Different from Site Addressl <br /> CITY STATE ZIP <br /> St0.--k+0r' GA 95ZO+ <br /> PHONE#. ER. APN# LAND USE APPLICATION# <br /> ( 1 <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR SUM PARTY❑ <br /> RHL pe5i n �ouP , Inc . ( fin : -a2192 GIznino)— <br /> BUSINESSNAME PHONE# 3!3' Y1DC' ur• <br /> RHL Grote Inc• 925 214 <br /> MAILING ADDRESS FAx# <br /> 13,10 yjillou Pass rGox! 5ur}e 420 125 (om- ln3o4 <br /> F.rl14br.i STATE ca Zw 14520 <br /> BILLING ACKNOWLEDGEMENT: I, the Undersigned property or business owner,operator or authorized agent of same, acknowledge that all site ardor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONLIENTAL HEALTH DwioN hoary charges associated with this Project at activity will be tidled to me or my business as identified on this forth. <br /> 1 also certify that I have prepared this application and that the work to be perfonled will be done in accordance with at SAN JOAQUW COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL Taws. <br /> APPUCANT SIGNATURE: pe RNL 0"n 61-061F , InG. DATE: 12/14-/_`—�—�I y r` <br /> PROPERTY/BUSINESS C OPERATOR/MANAGER ❑ OTHER AUTHOR=AGENT a'Pt•ot (.�torini;naifor��C TOT' <br /> dAwL.cwramrtlhe BAuhaPurrr.Pivot ofaodhatadon m sign ar Tww —� iitte 7056C>AUTHORRATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address.hemoy author®the release of <br /> any and all results,geotechnical data an Yor anvironmentaltsite assessment information to the SAN JGA0 uW COUNTY Puet1C HEALTH SERVICEs ENVIRGNA6lTAL HEALTH OMSION as soon <br /> as it U available and at the same time it's provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: I �,u�5�,/�pl�N <br /> f J'1tl tlVI GI• [ <br /> K/P <br /> DEC 2 2 1998 <br /> SAN JUFUUIN GUUN'fY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEAITH ORASKIr� <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVEDBY: /,1� .� EMPLCY--A: DATE: <br /> AsSIGNEDTO: /,� EMPLOYEE#: / Z11DATE: Z 2 C <br /> Date Service Completed (it already completed): PIE:. . o <br /> Fee Amount v Amount Paid 'L Payment Date <br /> Payment Type Invoice# Check# Received By: <br />