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06/09/2000 13:40 <br />A, <br />2095994249 <br />0 <br />FLYING J <br />• <br />SERVICE REQUEST <br />Type of Business or Property <br />' <br />� l <br />FACILITY ID # <br />X <br />,,_ <br />SERVICE ftc,;�cS'; i* <br />QWNERI OPERATOR <br />SAN JOAQUIN COUNTY <br />BILLING ?ARTY'' <br />FACitJTY NAME <br />PUBLIC UICES <br />ENVIRONMENTALLTH HHEAL DIVISION <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />T7ry� <br />i <br />Suh�t I <br />Mailing Address (If Different from Site Address) <br />EMPLOYEE #: DATE: <br />Gmr ( <br />STATE C'T ZIP <br />Y <br />PHONE #1 <br />EXT. <br />APN # <br />t-1No UsEAPPUGON # <br />ATI <br />PHONE#2 <br />EXT, <br />BO$:D1STR10i <br />Fec Atttounk: <br />LOCJITIONCODE - <br />CONTRACTOR 1 SERVICE REQUESTOR <br />REOUESTOft <br />SUSlNE55 NAME L:bn (we, <br />PHo�E R _ � - - -- <br />I 53�-9j`r�C' <br />1° MAULING ADDRESS FAx <br />a�K �7G� <br />IC" 80, re -- STATE <br />BILLING ACKNOWLEDGEMENT: !, the underi ned property or business owner, operator or authorized agent of same, acknowledge that a(I s;;e <br />PU8LIC HEALTH SliR=CS ENVIRONMENTAL HEALTH D.W1 ON hourly ChzrgeS assodalN with this project or activity will be billed to mo or my business as iden;tfied of; t,u iGil.. <br />t aISO Cerdfy Nat I have prepared this a lication and that the work to be performed will be done in accordance with all Sur JOAGUIN COUNTY Ordinance Codes, Standards, STAT-. arc <br />FEDERAL laws. <br />APPLICANT SIGNATURE: DATE: �/ J <br />PROPERTY I SUSINESS OWNER rJ OPERATOR I MANAGER OTHERAUTHmzFDAGENT 0 <br />11APPt c wr is naf Ne 01Lf& Pwry Proof of #urhorfrarfon to sign is muirvd Title <br />AUTHORIZATION TO RELEASE INFORMATION: When appkabte, 1, the owner or operator of the property located at the above site address, hereby authorize the release c: <br />any and all results, geotechnical data and/or environmentallsito assessment information to the Sur JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENvIRONMENTAi. HEALTH Dmsicci <br />as it iv available and at the same time it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />%r&,, f -fir' f Tj/n0 <br />(,IST Pte ,-, �-� P19-rv1 i A� <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />JUN 14 2000 <br />SAN JOAQUIN COUNTY <br />PUBLIC UICES <br />ENVIRONMENTALLTH HHEAL DIVISION <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY:, <br />, r, <br />EMPLOYEE #: DATE: <br />/ <br />ASSIGNED 70: <br />EMPLOYEz `7 DATE. <br />Date Service C <br />plated (if alrea y completed): <br />SERviCE GODS: <br />Fec Atttounk: <br />Amount Paid <br />X023C�; PaymentDatc (o � �' ov <br />Payment Type <br />Invoice �' <br />Check # cj�� `J -/ <br />Received Dy: UXisr_, <br />