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SERVICE REQUEST <br /> Type of Business or Property FACILITY IG# SERVICEQUEST# <br /> 03a. <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS a <br /> 4 4C) w 'CI�RRStreet Number Direction WEST CHARTF1$et WAy Type Suite tt <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> i <br /> CITY STATE ZIP <br /> TRACY CA 95378 <br /> PHONE#1 ExT• I APN# LAND USE APPLICATION# <br /> ( 209) 833-6427 <br /> PHONE#Z EXT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADORES <br /> CRAIG <br /> BUSINESS NAME PHONE# Ex-r. <br /> FTT-T-NER rONSTRUCTION., INC ( 916) 372-1 9,95 <br /> I[CHOM:E <br /> Or MAILING ADDRESS FAx# <br /> 3633 SEAPORT BLVD ( 936) 272-0911 <br /> WSTATE ZIP <br /> EST SACRAMENT <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br /> associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this appl, no and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ATE a d FEDERAL la <br /> .xPPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/ BUSINESS OWNER OPERAT NAGER JL—,f /Aai—eLSerr <br /> If APPLICANT is nor the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and <br /> at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: i :JC_���` <�71 <br /> COMMENTS: a t <br /> 19A9 <br /> SAN JUnUu N CUUNTY <br /> PUBLIC HEALTH SERVICES <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: ENVIRONMENTAL HEALTH ONISION <br /> APPROVED BY: ^ �_ r/�1� EMPLOYEE#: CJ I DATE: SI tq 9 <br /> 0o 1 <br /> ASSIGNED TO: `LOO EMPLOYEE#: 1 OATS:ul-t V 31'�G� <br /> Date Service Completed (if already completed): SERVICE CODE: ()-2 P i E: 2-36 <br /> F <br /> ount: � Amount Paid Payment Date <br /> t Type I Receipt# i C eck # Received By: <br /> - )Z : <br /> SRRL-Qrev.doc 7/1/1999 <br />