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Type of Business or Property SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST <br /> {Equipment M-,4 —4. an <br /> OWNER/OPERATOR 0 <br /> A. Teichert & Son, Inc. BILLING PARTY❑ <br /> FACILITY NAME <br /> Mobile E ui ment <br /> SITE ADDRESS <br /> 120 <br /> SIrrelllwnoa Dlrfoon Frank West Cirai.L ... <br /> Mailing Address (If Different from Site Address, rro� <br /> P.O. Box 15002 <br /> CITY <br /> Sacramento STATE ZIP <br /> PHONE#t APN# <br /> (91 Q 386-6916 193-360-36 LAND USE APPLICATION# <br /> PHONE#2 EXT <br /> (91Q 296-6319 SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUFSTDR <br /> George Takemori BILLING PARTY Q <br /> BUSINESS NAME <br /> A. Teichert &- Sori--mac, _.. - -----.. PHONE# <br /> MAILING ADDRESS <br /> 91 386-69-+ <br /> P.O. Box 15002 FAx# <br /> CaySacramento 91 386--1256 <br /> STATE CA ZIP <br /> BILLING_ ACfCNOyyLEDGEMENT; I, the unders' ned roe 95851 <br /> Property rty or buslnesq owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this Project or activity wig be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIH COUNTY Ordinance Codes, Standards, STATE <br /> FEDERAL laws. <br /> and <br /> APPLICANT SIGNATURE: <br /> DATE: 8-11-99 <br /> PROPERTY/8USINESS OWNER <br /> OPERATOR IMANAGER 0 OTHER AUTNORIZEDAGENT 0 Project Engineer <br /> If APPLC.Wr is not it"U c &E—Ada pal of aumoriiadon to sign is npu6vd <br /> AUTHORIZATION TO RELEASE INFORh1ATI0N:When applicable.I.the owner or operator of the roe cillo <br /> any and all results,geolechnical data and/or environmentaUsile assessment kilo madon to the SAN JOAOUIN-000NrY PUBUc HEALTH SERVICES ENVIRONMENTAL H <br /> as it is available and a1 the same time it is provided to me or my representative, P P located at the above site address,hereby authorize the release of <br /> HEALTH DNISION as SOOn <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: - - - <br /> AYMENT <br /> AUGUM9 <br /> NU.hro,I QA(j v <br /> INSPECTOR'S SIGNATURE: ENVIR NMEH LTH GERVI" <br /> APPROVED BY: l� CONTRACTOR'S SIGNATURE: MOLTIi M14,6 ON <br /> �C EMPLOYEE r#: DATE: <br /> ASSIGNED 70: �-+ <br /> EMPLOYEE : DATE: <br /> Date Service Completed (If already Completed: <br /> Fee Amount: $ SERVICE CODE: I PTE: Z <br /> Payment Type If(rg Amount Paid $ � <br /> I !90 Payment Pate <br /> Invoice# Check# <br /> �?�`� Received By: <br />