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1 y,/10/2000 09:46 <br />A <br />2095994249 <br />is <br />FLYING J <br />SERVICE REQUEST 9 <br />PAGE 03 <br />Type of Business or Property <br />_ <br />FACILITY ID ## <br />SERVICE REQUEST # <br />RECEIVED <br />Z <br />�� <br />$ <br />iA lilJlJ lS1 <br />ENVIRONMENTAL HEALTH DIVISIO i <br />OWNER I OPERATOR <br />CONTRACTOR'S SIGNATURE: <br />BILLING PARTY 0 <br />FACILITY NAME <br />EMPLOYEE #: j .�<i <br />DATE: <br />n <br />AsslGN£D.T0- l V� <br />i -s 07 <br />EMpLoYEE #: �/ V? <br />DATE: <br />Date Service Completed (if already completed): <br />5r[E ADDRESS <br />Fee Amount:i <br />��Z.17 (--- <br />✓ A L�CiI�+i• <br />Payment Date <br />Eayent Type Ur is invoice ' <br />xl, <br />p st.■t Mumb.r <br />Idon <br />Strhl N.m• <br />D• <br />SuN�I <br />Mailing Address (If Different from Site Address) <br />Cmr • <br />1 <br />STATF ZIP /- <br />PHONE 91 <br />APN ft <br />).AND VsE APPLiwiON 9 <br />PHONE #2 <br />HOS,CtsTalCT <br />LOCA16 CODE:. <br />CONTRACTOR t SERVICE REQUESTOR <br />B1WNG ACKNOWLEDGEMENT: t, the undersigned property or business owner, operator or authorized agent o/ sama, acknowledge that all site and/or project specific <br />PLIK;C HEALM SERVICES ENVIRONMENTAL HEALTH OmS10N hourty charges associated with this project oraaFrity will be biCed to me or my business as identified on thio form. <br />1 also cerdfy that I have prepared this appllcatiorrj. Ne work to be performed willbo done in accordance with all SAN JOAOUIN COUNTY Ordinanco Codes, Standards, STATE and <br />FEDERAL laws. <br />APPUCAHT <br />DATE:fb e." <br />PROPERTY! BUSINESS OWNER ❑ OPERATOR! MANAGER A OtHERAtmmzEDAGENT a <br />ItAPPLcmr is not the B&Lm PurrY proof of juthorri/tion to sign Is rspulrad Title <br />AUTHORIZATION TO RELEASE INFORMATION: when applicable, t, the owner or operator of the property located at the above site address, hereby authoriza the release of <br />any and all results, geotechnical data and/or environmentaVsite assessment information to the SAN JOAQUIN COUNTY PunuC HEAr m SERv)GCS ENVIRONMENTAL HSAt W DNISIOM as soon <br />as it is available and At tha same time it is pmided to me or my representative. <br />TYPE OF SERVIC$ REQUESTED: <br />_ <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />Nov 3 0 2000 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISIO i <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY:. J r <br />EMPLOYEE #: j .�<i <br />DATE: <br />n <br />AsslGN£D.T0- l V� <br />EMpLoYEE #: �/ V? <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE. � $' I E: �pg • :... <br />Fee Amount:i <br />��Z.17 (--- <br />Amount Paid 1� a — <br />Payment Date <br />Eayent Type Ur is invoice ' <br />Check a 1.2 1o�3-0 X623 y Received By: <br />Ja133.1-1 (I*2q ) <br />