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(a SERVICE REQUEST EH0061SR revised 09/04/98 Type of Busin?ss or Property 3 enhone C' m Tn i rat ions FACILITY ID # SERVICE REQUEST # OWNER I OPERATOR AT&T Communications BILLING PARTY ❑ FACILITY NAME AT&T SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES ENVIRONMENTAL WEALTH DATE: � SITE ADDRESS Street Number 110 Direction West Turner ROa&eetName Type Suite# Mailing Address (If Different from Site Address) CTY Lodi STATE CA zip � PHONE #1 EXT. APN # LAND USE APPUCATION # PHONE #2 EXT• Payment Date 2' BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Gary Ny=n BILLING PARTY BUSINESS NAME Inc-Kyaerner Aronson, PHONE# - EXT. 1910631-1646 MAILING ADDRESS 11297 Coloma Rd. FAX # 016)631-0437 CITYRanchoCordova STATE CA zip 95670 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/Or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared th' application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, ST n FEDERAL laws. APPLICANT SIGNATURE: DATE: November 1998 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER xx OTHER AUTHORIZED AGENT ❑ If APPLICANT Is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: t j �\e'L(rI - �� COMMENTS ❑ SPECIAL CONDrrION(S) OF APPROVAL ❑ -- - -- -- OTHER — _ _ __..__� ❑ PAYMENI RECEIVEn NOV 2 41998 INSPECTOR'S SIGNATURE: CONTRACTOR's SIGNATURE: SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES ENVIRONMENTAL WEALTH DATE: APPROVED BY: EMPLOYEE #: DATE: ASSIGNED TO: �� -? EMPLOYEE#: . DATE: Date Service Completed (if already completed): SERVICE CODE: / % P l E: `T-- Fee Amount: Amount Paid _ �,. Payment Date 2' Payment Type/,�, Invoice # Check # Receival By: