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1T�!l• SERVICE REQUEST <br />Type of Business or Property FACILITY ID <br />A�.c a Am -Pr✓� q� <br />OWNER/OPERATOR J /�• <br />ARCO /�C! tLC��J L,�7 <br />SERVICE REQUEST <br />JR � c�� <br />BILLING PARTY <br />FACILITY NAME I,V A41971 -01-51 <br />MAILING ADDRESS ';?-goosL J' 6I)a r�D� <br />SITE ADDRESS .56/ <br />SVWNnmeM <br />e/y,�gyt �a✓K' <br />draNnn Slnrt Neme <br />iy0e <br />SeiU1 <br />Mailing Address (If Different from Site Address) <br />Cm Lcr) <br />STATE ` ZIP <br />PHONE »1 <br />( <br />APN» <br />LAND USE APPLICATION <br />PHONE »2 Esr. <br />BOS DISTRICT <br />APPROVED BY: M r <br />LOCATION CODE <br />CONTi)ACTOR I SERVICE REOUESTOR <br />REOUESTOR BILLING PARTY O <br />,» % <br />BUSINESS NAME - <br />PHONE» Ear. <br />MAILING ADDRESS ';?-goosL J' 6I)a r�D� <br />FAX» � <br />fD✓- <br />CRY '-rTCI10 6O/YIUrp' STATE ZIP <br />BILLING ACKNOWLEDGEMENT. I, the undersigned property or business owner, operator or authorized agent of same, a&nowtedge that all site and/or project speelic <br />�;�'.". ` Jlrr' _sN: ; :.yvra.+nrtDl Fr 3L'r' Orir,::•t Mr:r`(': �.: e] ate. �'M wM'hG r.•j?'X :r a :'i'r?( •nL hP, h�?M b m! a my 6e]inKs a� Nentl5M on the I�rrn. <br />1 also rnrdfy that I have <br />FEDERAL Iaws. <br />APPLICANT SIGNATURE: <br />PROPERTY/ BUSINESS OWNER <br />and that the work to be performed will be done in accordance with all SAN JOAGUIN COUNTY Ordin�a/nnCeeCCOdeS, SfandafdS. STATE and <br />DATE: //�/r�-�L �( / <br />OPERATOR/ MANAGER O OTHER AUTHORIZED AGENT <br />PouJwr/7A <br />BAis oaf the flumPARry proof of wdrodradon to sign h Abad - rai. <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable. I, the owner or opemlor or the property loaled at the above site address. hereby authorize the release of <br />any and all results, geolechnial data and/or environmentaUsits assessment information to Use SAN JOAQUIN COUNTY Pueuc HEALTH SERVICES EwHoHMENTAL HEALTH OPNs*N as soon <br />as it is available and at the same time H is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />( �L0 n- <br />T <br />n . -L J 1�q � <br />COMMENTS: <br />j <br />CCI-ij nek,7 <br />/r tsf` --p -oc� la�i�� mss_ l <br />C"AYMEN <br />REeFRuLzD <br />FEB 2 5 1999 <br />INSPECTOR'S SIGNATURE: <br />VlsjlTljJOAQUIN COUNTY <br />l , HFAI.7Tj SFTTVI CS <br />CONTRACTOR'S SIGNATURE: F_NVIRONME ITA,ON <br />APPROVED BY: M r <br />� <br />EMPLOYEE »: o � ��- <br />DATE: <br />ASSIGNEDTO: D I <br />EMPLOYEE»: V3 <br />DATE: <br />I <br />Date Service Completed (if already completed): SERVICE CODE: <br />P I E: ;JL3 03 <br />D3 <br />Fee Amount: 6 <br />OC -gr b0 Amount Paid as 1 Payment Date a1-;LS/9 <br />Payment Type ✓ <br />Invoice OSAM45 Check I j xte a) <br />fteeeived By: <br />� .5 ,n,a,,a a�-�--t. ry 3•�-� ' nr�d�-P - � Sf _av � � ct�l:v� <br />�j3.oa53�°Q� U� <br />