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10/23/00 17:02 $510 6564320 PROLOGIS 0 002 <br /> "ti,... <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID ff SERVICE REQUEST# <br /> OWNER l OPERATOR GUM PARTY Lj7'F <br /> r7ALY c°�mry�e >t�c <br /> FACILITY NAME <br /> SITEADDRESS <br /> $lreelltvnbc DkecEon Y4edamro T� $�{trf <br /> Mailing Address (If Different from Site Addressl <br /> 777 S /=`�•;/}7Gx/iL Y`i� <br /> CITY STATE zip <br /> h' rr ANT" c /9 ) S 36 <br /> PHONEffi EV- APN$ LANoUsEArpt.a: lKm4 <br /> (tiFo) <br /> &'-'7-6—/ 900 Z.ag — // --Z0 0070 <br /> Pa'lotra 12 BOS DISTKICT LOCATION COoE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> R[QuLSOR BIUJNS PARTY 0 <br /> BUSINESS NAME �t �^ PHONE W <br /> f9 <br /> � /) <br /> MAILING ADORL sS r 0<7 5--X /�T_V h Z/ — FAX 9 <br /> CITY 6 STATE ZIP <br /> BILLING ACKNQWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent oT samo.arMomedge That all site andtor omvW spetarc <br /> PUBLIC HEALTH SERVICES EWRONMENTAL HEALTH OM.SIDN hourly Charges associated with this project or ac ivity will be billed to ole or INy b"@ss as IdenUfled an titls form- <br /> t also cer0f that I have prepared this application and that the work to be d will be done in acootdance with all SAn JOAQUIN Cairn OrtAnanco Codes.SLvrdort/S.STATE and <br /> Frtor-, r-taws. <br /> APPLICANT SIGNATURE; DATE: <br /> PROPERTY IBUSINESSOWNER L} OPERATOR IPoIANAGEA I- OTHER AUTHOW1[oAGCM <br /> ifATrurarar;arado St i m PNvr•r proof ofauUxAzadontosign isrpuind Titre <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of Use properly hated at Iho aLovo silo address,hereby authorize the release or <br /> any and all re„u1ts.geotechnical data andfor environmentaUshe a—essment Worm30on to the SAH JoAouw Couwy PuerX;HFA TH SERVKFS EMMOt MENTAL HEALTH DMSIDN as seen <br /> as it is available and at the same time it is provided(o me or my represenlative. <br /> TYPE oa sarrnct Renut:sT>:D:.r l t. �4 0 e --t,t t_� '` ( � �' �:.;\�zk-1)I 111 C L4 r L4'� <br /> COMMENTS: <br /> NAV 242 <br /> SAN JOAgLIIN CORN j V <br /> PLI$L4 IIEW-TH SENViCES <br /> r'4VIAON1,AENTAL HEALTH DIVLctUN <br /> INSPECTORS SIGNATU CONTRAGTOR'S SIGNATURt: <br /> APPRt}Vgli or.. �_r? EMPLOYEE$: fcc) 1 RATE:5— <br /> .3(-( C 11 <br /> ASSIGNEDTO: t 't\ EMVLoTEES: �/C. •f DATE <br /> Date Service Completed (if already completed: T SEttvtcr CovE -cr•3 I P/E:'7(I• <br /> Fee Amount: , , Amount Paid �(04N Payment Date <br /> Payment Type Invoice 4' Check# Received By: <br />