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5-27-04; 8:43AM; -925 551 7888 5/ 34 <br /> 031 05/2004 16:18 <br /> 18 2094683430 !FIFTH FLOOR PAGE 05 <br /> SERVICE REQUEST <br /> lwype of Business or Property SEMCE REQUEST# <br /> FACILITY ID# r <br /> cS' <br /> "4000 <br /> 3qO 1 0 0 <br /> 16 01 ISVITCHI"Cl T-.IVC14L— C/C? ofb s <br /> qER OPERATOR BILLING PARTY O <br /> ifygy NA11r; <br /> WADORESS <br /> ifing Address (if Different from Site Address) <br /> ar,C)C,> <br /> :rTy STATE 7jP <br /> APX# LAND Use Am=-nofi 9 <br /> NE#2 N <br /> CONTRACTORISERVICE MQUEMIR <br /> Questotz BUJAG FMIX <br /> Dy I <br /> WIM?us RAME PffONEN <br /> A&IROQ-- k1c <br /> r <br /> NG,000RESS FAX 0 eft dLaj <br /> FAX <br /> 1c,-C <br /> STATE 0,4, ZIP <br /> KING ACKNOWLEDGEME 4 the undersigned pmpwty or business ower,operator or authorized agent of same.acknmWqe that all 9b and/or project specific <br /> HaAuti SERWS EtMRONmWAL HMTH Dmsw hourty charges assadated with Ihis project'®r ac9ftwin be bled to me or my business as ideaffied ort this 10ML <br /> Iso cerci ry M I have to red this appfication and that the work to bo Womied will be do4e in a=dance wib al SmloAmm Coum 06amm Wes;Standards,&ATE and <br /> rtcAr. <br /> laws,T SIGNATURE: GL WE: <br /> 1 u <br /> OPERTWBUSINM OWNER 0 OPERATOR/MANAGER 0 Ofl4eRAVMM2EDAuw Rf <br /> L <br /> ItAw-w'rhr' <br /> -fkf-v pmetoliuModudan tojIgn h"ivd <br /> - 'd d Title <br /> OR17ATION TO RELEASE INFORMATION:Whon applicable.I.the ummtr at operator of the property)orated at the above sile address,hereby authorize the release of <br /> and al results,gealedidical data andfor environmwiallala assessment informationto the SAN 10 um CaJNW FUME IiMTM:Sw&=ENVIRONWwAt HEALTH 0NMxw as soon <br /> 1 is avabble and at 1he same drne it is Provided to me or my fepfCSentaIIVe- <br /> OF SOME REQuESTFO: <br /> E�IVEI) <br /> ii <br /> OCT 2 0 2203 <br /> SAN JOAQUIN COUNTY <br /> am PUBLIC HFALTH SERViCES <br /> RONMEOTAL HEALTh olviSIDIq <br /> ITOR'S SIG[LAME: CnNTPACTOFeS SICRATURE: <br /> ROVeO aV. EMPLOYES-9: DATE; <br /> FDATE:.EE <br /> :Service Completed rif already completed), <br /> ERMECODE: <br /> rPIE:., <br /> P <br /> wHunt: aid Payment Date <br /> - q*z I <br /> Hent Type <br /> Invoice 9, check# Received By: <br />