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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD IDN .5 INVOICE it <br /> FACILITY NAME US POS`'' "—'"'""e"- c;f nrkfrYn Tom' BILLING PARTY Y / N <br /> SITE ADDRESS 3131 Arch Road - <br /> CITY Stocton CA ZIP 95201-0388 <br /> OWNER/OPERATOR US POStal SerV1Ce BILLING PARTY Y / N <br /> OBA USPS PHONE #1 ( 415 ) 742--6337 <br /> ADDRESS 395 Oyster Point Boulevard #225 PHONE #2 ( 415 ) 794 - 0820 <br /> CITY South San Francisco STATE CA zip 94(109—(1"210 <br /> APN # p Land Use Application # <br /> BOS Dist Location Code <br /> T <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR GHH Engineering, Inc. BILLING PARTY <br /> DBA PHONE #1 ( 916 1723 -7645 <br /> MAILING ADDRESS 8084 Old Auham Road #E FAX # ( 916 )723 •7698 <br /> CITY Citrus Heights STATE CA zip 95610 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknow Ledge that all site end/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> .o��Y9lR�N'lT <br /> I also certify that I have prepared this appllca ion and that the work to be performed wiLL be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes Standards S a an Federal yaws. <br /> APh i r 199$ <br /> APPLICANT'S SIGNATURE <br /> Title: President Date: April 7 1998 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicabLe, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environments L/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request: 1611 <br /> /� z m�J�j� '� Servlq COda 9 Q_ <br /> Assigned to ,�, �i �i Cy IC✓� � Q�/Jr Employee # Om 9 Data <br /> g yY�- <br /> Date Service Completed Further Action Required: Y / N PROGRAM ELEMENT U <br /> Fee Amount Amount Paid Date at Payment Payment Type! Receipt # Check # Mcvd gy <br /> RENS " i _.� /= , UNIT CLK <br /> /� SUPV _ '_/_ ACCT _�__/_ <br />