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r .► <br /> SERVICE REQUEST <br /> Ty a of Business or Property FACILITY ID# SERVICE REQUEST# <br /> electrical Power Generation <br /> BILLING PARTY ff <br /> OmERI OPERATOR <br /> AC <br /> FACILITY HANE <br /> STIEADDRESS I West Washington Street TM sea.: <br /> 2526 Su,w Numbv pncsen <br /> Mailing Address (If Different from Site Address) <br /> STATE ZIP <br /> CrrY CA 95203 <br /> Stockton <br /> LAND USE APPLICATION <br /> PHONE#1 W. APN# <br /> (209) 467-3838 14 145-030-009 <br /> PHONE92 ,m. BOS DISTRICT _ LOCATION CODE.. <br /> CONTRACTOR/SERVICE REOUESTOR <br /> BILLING Pum❑ <br /> REQUESTOR <br /> Andrew Safford, P.E. <br /> PHONE# <br /> BuswESs NAME 65q 292-9100 <br /> Erler & Kalinowski, Inc. <br /> FAx# <br /> MALNG ADDRESS (,50l552-9012 <br /> 1870 Ogden Drive <br /> STATE LP <br /> Qm Burlingame CA 94010 <br /> BILLING ACKNOWLEDGEMEM: I,the undersigned property or business ovmar,operator or authorrted agent of same,acimmedge that all site andlor project srecfic <br /> PVSUO HEALTH SERVICES ENVNONMENTAL HEALTH DMsciN hourly charges associated with this Projed Or aclmty will be billed to me or my business az Identified on this toren. <br /> I also minty that I have prepared this appliCeton and that work be pedo Will one in acowmanm with all SIN JOAGUN CWtrtY Orrlinenca Codes,Standards.STATE and <br /> FEDERAL laws. f — <br /> DATE: /� J <br /> APPLICANT SIGNATURE: <br /> PROPERTY I BUSINESS OZER OP TOR/MANAGER 0 OTHER AUtHORtffOAGENi fl rifle <br /> NA�ftcWr¢ncf the BL"`-PArtrY poen/o/aufhaiatlw b syn h requeed <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.4 the owner or openiteref the property khated at the above she address.hereby authorim the release of <br /> any and all results,geotechnical data andlor emuorment illslle=eSsmenl Information to the SAN IOAOUN COUNTY PUBUC HEALTH SERVICES EtMRONMFNrAL HEALTH DIVISIGH az soon <br /> as It is available and at the same time a is provided to me or my representative. <br /> TYPE OFSERVICE REQUESTEO: Oversight of soil sampling beneath used oil tank. <br /> COMMENTS: - �1�``' \�G�• <br /> r <br /> l`TPN 0 N P,t N R�GC J�gV <br /> P�BUMEN1p� <br /> �NN�pN <br /> INSPECTOR'S SIGMA CORTRAQOR'B SIGNATURE: J� <br /> APPROVED BY: EYPL.^Y_#' .3� / DAA- <br /> ASSIGNED TO: <br /> t# <br /> ) E9PLOYEE#: Cb3 <br /> Date Servicedy mpleted):Completed (d already <br /> SERVICE CODE: �U/- 'PIE: <br /> Fee Amount �i'7L?C0 Amount Paid �� oo Payment Date <br /> Payment Type Invoice# Check it �(�g3 Received By: <br />