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12/18/98 FRI 09:36 F1X 5106096304 RRL DESIGN GROUP a+� RNL PETALU31A Q015 <br />SERVICE REQUEST <br />Type of Business or Property <br />BILLING P.AIM ❑ <br />FACILITY 10 # <br />Pw 33 S- 5- <br />SERVICE REQUEST # <br />GAS S-rA710CJ <br />_ <br />FAX# <br />7tn -165-IJO'B <br />Cm Pe. � cL I LA M It <br />0/7'770 <br />OWNER OPERATOR <br />APPROVED DY: �r <br />BU.LJINI �[ <br />" <br />IVICI< tyt0�(faL <br />_ <br />DATE:-�./-�'� <br />Date Service Compieted (H already completed): <br />FAOILRY NAME <br />AIRPORT Shell <br />Fee Amount: <br />SITEAOORESS 1-313 <br />E. <br />I <br />ChCir4er <br />Invoice # <br />�UAy <br />Check # <br />stat Nu <br />ousmon <br />ss.mbNt <br />T1v. <br />Seees <br />Meiling Address (If Different from Site Address) <br />U. $OX So SD <br />CmMA>`TINEz <br />Sra CA LP `l L4553 <br />PHONE 91 EAT. <br />-757-k995 <br />APN# <br />151-3-70- C-7 <br />LANDUSEAPPUCATtcm# <br />(9s) <br />PHONE #2 Ext. <br />BIDS DISTRICT <br />LocAnON CODE.. - <br />CONTRACTOR I SERVICE REOUESTOR <br />REQUESTOR <br />Sr��� Skallo�Rsa>J <br />BILLING P.AIM ❑ <br />BUSINESS NAME <br />�1�� �ES1E,n7 Grou <br />Pw 33 S- 5- <br />PHONE#• <br />7u7 �bs-Ibbo Zftb <br />MAILING ADDRESS <br />113 N. M' Dowell C3Wra <br />_ <br />FAX# <br />7tn -165-IJO'B <br />Cm Pe. � cL I LA M It <br />STATE C Pr ZIP Iy 1 7 pry / <br />BILLING ACKNOWLEDGEMENT: I. the undersigned pmpetty or business owner, operator or authorized agent of same. ad noWedge that all sde andtor project Spealic <br />PUBLIC HEALTH SERVICES FW ROHM NTAL HEALTH DwtS QN noUrty ChaMeS 35SOC7a2•d web this project or ao" will he dlesd in me or my business as identlfied on m6 form. <br />I also emaN that I nave Prepared this application and that the work W be performed wig be done in accodan�ree welt WI SAN JOAa N CauNTy Ordnance Codes, StandaNs. STATE and <br />FEDERAL 13M.�., d <br />APPLICANT SIGNATURE: DATE: <br />s <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR I MANAGER 0 OTHER AIRNORzED AGENT <br />JAPRIcurt4r"ff06Iu.M Am. pmdofwdmMnthnmrtsanisreou6ad' Tilts <br />AUTHORIZATION TO REL EASE INFORMATION: When applicable. 1, the owner or operator d thepm=kwuWat the ease address, hereby authors the release of <br />any and as msul6, geoteMnIcal dans anoifor enymnmentaYsee assessment InIOMMU n to fie SAN JOAQuvt COUNTY PUBLIC HEALTH S ENVIRONa@nAL HEALT1 Onn51ON as soon <br />as it is aveeabie and at the same time it Is Provided In me or my Iepre,enmWe. <br />TYPE OF SERVICE REQUESTED: 'Pec ry)a rl e11 <br />of nk OSQCNO. -� <br />COMMENTS: .{/.. e/-f't3'gq <br />Pw 33 S- 5- <br />f/err A �j d r- <br />_' F <br />Lu olx) <br />_ rrr a aver GY V i <br />�o �s33o RECEIVED <br />DEC 21 1998 <br />INSPECTOR'S SIGNATURE: <br />SAN JOAOUIN COUNTY <br />CONTRACTOR'S SKaNA7URE. PUBLICWPAIT <br />DATE: H�/T1I a <br />APPROVED DY: �r <br />EMPLO-ySEt: C�// <br />ASSIGNED TO: <br />EMPLOYEE#: J <br />DATE:-�./-�'� <br />Date Service Compieted (H already completed): <br />SERVIGECODE:- <br />Fee Amount: <br />id <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />