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013/ii/200b 09:52 209468343 FIFTH FLOUR HAuL X12 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> P R C—1 I C ` _ �^� SERVICE REQUEST# <br /> Q q� 5 - <br /> OWNER(OPERAToR <br /> AG �C L L, BILLING PAR1Y O <br /> FAcluTy NA14E <br /> ?PiG GLI,.. <br /> SITE ADDREESS <br /> 8 i 2 StrutHunZvr Olrccdan C OLEY Z)VE. <br /> Strut Ham4 T�� sunt <br /> Mailing Address (If Different from�Site Address) <br /> '5t3M <br /> CrrY <br /> $TATE zw <br /> pFIONE#t Ea. APC!# UWOUSEAPPUCAT{ON# <br /> PHONE#2 'Err. $DS•DtsTt>rcr' <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REaUESTOi2 <br /> SLUNG PAPTY❑ <br /> .�4�`i 5T1�EtTZ <br /> EuS14ESS NAME PHONE# <br /> �TF3 jT �iv✓t�oN/Y�tni TY-)L 7-b-my 4lis(ao -,3zz <br /> MAILING ADDRESS �� FAX# <br /> �A R�Gc�v��2 y 5Zu0- 8Z34 <br /> CnY 5 P1N A N( STATE C/1 Z1P <br /> BILLING ACItNOWLEDGEMENT.' 1. Ute undersigned property or business owner, operator or authorized agent of same, ackriowWge that all site and/or projeci specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAI,HEATH DIVIS1oN hourly charges assodated vrith this projea or activity wID be billed to me or Rry business as identified on this farm. <br /> I also certify that I have prepared this applicat on and that the work to be performed will be done in accordance wilh all SAN JOAQUIN COUNTY Ordinanco Codes,Standards,STATE and <br /> FEDERAL.laws. <br /> AppucANT SIGNATURE: DATE. TA <br /> PROPERTY/BUSINESS C1OPERATOR/MANAGER 11OTHERAUTHORl1EDAGENT ZL VSrE/►!5 <br /> YAPR.rcwris(414W Bnr>vcPNrrv.proof claufborizatlon ro afvu Is rnqufrvd rruo <br /> AUTHORIZATION TO RELEASE INFORMATION:When appacable,1,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmental/siia assessment informakrl to the SmjoAWLw CCUNTV PUBUC HEALTH SERVICES ErrVIRONMENTALHEkTH DIvisIDN as soon <br /> as It is available and at the same time it iv provided to me or my reprasentahe. <br /> TYPE of SERVICG REquriSTED: <br /> U 5 T IWON- I7Zk lno&F 164770A) <br /> COMraL•NTS: <br /> T <br /> • P ECE vED <br /> R <br /> SEP 19 2��� <br /> ouTN s�v�GEs <br /> SPU6�OHEPISN p,�THDN\S10N . <br /> �NVIRONMEN�A� <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVCD eY:. EhiPLOTE,#: ()O(j ( gDATASSIG2IEDT0: EMPLOYEE#: <br /> Date Service Co plated (if already completed): - .. <br /> SERVICE CODE: �� <br /> Fee Amattnt: 2 <br /> Amount Paid ( (TD Payment Date I_(-T-�7 <br /> Payment Type '1 Invoice#• Check# <br /> 1-70 Received By: ��� <br />