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0-6/27/2001 13:57 20946834 FIFTH FLOOR PAGE 05 <br /> SERVICE REQU55r <br /> Type of Business or Property FACILITY IDR SERVICE R5QUEST R <br /> SILLIHG PARTY 1! <br /> OWNER 1 OPERATOR <br /> FACUTY NAME UIKSTD/' M C3 �t/32 <br /> SiTEADORESS <br /> 135-5-5 We <br /> ® ® strett N� Type Sit e <br /> stre081d Gtnakn <br /> Mailing Address (If Different from Site Address) <br /> CrTY j/ MAJ STATE zip !�S <br /> Q—KO#1 Al Ecc APN# LANDMEAPPLICATION` <br /> PHON£92 Der. BOS DtSr= ,-. LOCA70H.CU . <br /> CONTRACT0121 SERVICc REQUESTOR <br /> 81t t MG PARTY d <br /> RI:auEsroR <br /> BUSINESS NAME !/9nitst..E ETIV/2.e�yt!/'9�x17x}C, /V(! . <br /> phi/� r) <br /> MAILINGADORE55a�25 ✓a . FAxM01 <br /> 6 _ 69.79 _ <br /> STATE ZIP 7®.D <br /> 31tt1NG ACKNOWLEDGFMrtNT:t,the uadems ned property or business owner,opcmtor'or authorke+d agent of same,adgMledge mat all site and/or project specfc <br /> PUsuc HEALTH StltvrGt s ENVprA AL TH OrVi=hourly dtatges associated with rhts pmjed or S=vfty wig be billed to me or my business as idenW*d an this form- <br /> I atSa certiy that i have prepared this apphoation and that the work to be performed,vil1 be done in as ardance with all SAN JOAQUIN CWKN Ordinance Codes.Standards,STATE and <br /> FEDERAL fawn. <br /> DATE: <br /> APPLICANT S=ATURE: r <br /> OPERATOR IMANAGER OTHERAUTmOMMAGWr d Qa�ir.Gr <br /> pRpP�ttYlBUSrNESSDYVNER <br /> P�fwto+dd rasi�sar�gr� Title' <br /> ffA?PiKUA'isnoriH09atAr3Fa9L�' <br /> AgIMORIZAT ON TO RELEASE INFORMA'nON:VOw applicable,I,the owner or operatnr of the property boated at the above site address.hereby authorise the release of <br /> any and all resultS,geotechnical data and/or a rihntREYl USite assessment 1nf0mt36an to the SAN JOAQlw CMM pusuc HEALnj SERvrcros ErMFZONAMAL HEALTH OMSKN as soon <br /> as it is avada®le and at the sante 6me it is provided to me or my represarnaeve. <br /> TYPE OF SERVICE REQVESTEC: <br /> COMMENTS: <br /> 1NspEcTOR's SIGNATURE: CONTRACTOR'S SIGNATURE' <br /> APPROVED Or up UT—MI. DAM . <br /> Ag$1GNE470: EMPLOYa#: DAT>~ <br /> Date Service Completed (if already Completed): SPgzvrE CODE _ PPE: <br /> Fee Amount: Amount Paid Payment Date: <br /> Payment Type Invoice# Check 4 Received ay: <br />