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SERVICE REQUESC' <br /> Type of Business or Property FACILITY IO# SERVICE REQUEST x <br /> Fallow land/Residence X00 702 <br /> OWNER OPERATOR BUMG PxM a <br /> Lero & Glenna Petz <br /> FAc1Lm NAME <br /> SITE ADDRESS <br /> 29300N,�, So ith� Bird Road sa..rR <br /> Ty" Suitt Y <br /> Mailing Address (if Different from Site Address) <br /> Cry ZW <br /> Tracy STATE CA 95337 <br /> k <br /> PHONE#'1 APN# LAND UsE APPucAnan# <br /> (209) 835-8808 255-020-63 SU-01-0004 <br /> PNDNE#2 SOS DZTR= LocAnoN Cone- <br /> CONTRACTOR f SOME REQUI=SrOR <br /> REwumott BILISIG PARW 1r <br /> Rod Attebery <br /> BUSINESS NAPE PHONE# [u <br /> Neumiller & Beardslee 20 48-8200 <br /> MAiuNc ADopm3 FAX# <br /> PO Box 20UQ2) 948-4-910 <br /> CITY ZIP ckton STATECA 95201-3020 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,oprrator or authodwd agent of same.atdula* Wgo that all 3Ae andlor project specific <br /> Puauc HEALTH SERvas ENVaRq1 VITAL HEALTH OMSM hourly charges associated with this project or aoAgty wia be bW to me or my business as idenwW on dab kung <br /> I also oanity that t have prepared this application and that the work to be pecfwmed wi he done in aoacudarwo with aft SAN JOAMM Coautrr Ordrnence Codes.Standards.STATE and <br /> FEDERAL lags. <br /> I <br /> AAPLAl Aex� <br /> IGNT SIGrtATr1RE: 69 DAZE: S— <br /> PROPERTYIww,=owsw ❑ OZORIMANAGER ❑ OTNERAtnx)R=AGENT Le a counsel„_ <br /> Y.SPPrcurrirrntthrA�r►r a.�vp�y�(dau7hartrirlonfvagoJsnQrrird Title <br /> AUTMORIWLQN-Ta RE4EASE INFORMATION:When applicable,Lam owner or ope rcf ttre property Wted at the above site address,hereby audtaize the miease of <br /> any and all results,geotechnical data am9or errrirorur>erTGilfsila a ssww ent iAwmallon m the SAN JOAQUIN COWff PUWX HEALTH SEMI-s FAvvtowAaax HE, -H Om=”as soon <br /> as 4 is available and at the lama time it is provided to me or my mprm3enta0m <br /> TYPE OF SERVICE REQVE: TW: <br /> Soils Suitabilit <br /> commam. <br /> S <br /> PAYMENT <br /> i RECEIVED <br /> AUG 24 2991 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH[]IVI510!v <br /> INSPECTORS SIGNATUR ' CONTRACT ORS SIGNATURE: <br /> APPROYMHT: .5 FstP19Yw�: /G l f !)ATE: 8-2e-1 0 <br /> I ASSIGHEtJTo: 57o_4( IV SfjlIl EtIPLOYEE#: 3F3(f DATE: 8-2y-o <br /> Date Service Completed•("rf already completed): StCooE: S z Z P I EE <br /> f <br /> Fee Amount I --- AmoUnt Paid -7$ Payment Gate <br /> Payment Type V/ Invoice 4 Check# 46 <br /> YrJ $ Received 8y:<:::e� 1 <br /> s <br /> 4 <br />