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SERVICE REQUEST <br />Type of Business or Property <br />Communications <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER/ OPERATOR BILLING PARTY <br />AT&T <br />FACILITY NAME <br />SITE ADDRESS <br />110 $tree! Yumber <br />Direcdon <br />West Turner Rd Sheat Name <br />Type <br />Suito 9 <br />Mailing Address (If Different from Site Address) <br />CRY STATE ZIP <br />Lodi Ca <br />PHONE #1 EXT. <br />( D <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2T• <br />TOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />BILLING PARTY IBX <br />Kvaerner Aronson Inc. <br />APPROVED BY: <br />BUSINESS NAME <br />DATE: <br />PHONE# <br />&T <br />Kvaerner Aronson, Inc.— <br />DATE: <br />(910 <br />631 - 1646 <br />MAILING ADDRESS <br />PIE: <br />FAx X # <br />Amount Paid Payment Date <br />11297 Colonia Rd. <br />Invoice # <br />01 <br />631-0437 <br />CRY <br />STATE Ca <br />ZIP 95670 <br />Rancho Cordova <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business 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 will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this <br />FEDERAL laws. A <br />APPLICANT SIGMA <br />PROPERTY/ BUSINESS OWNER <br />and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />DATE:—,?// I�/q <br />/ MANAGER x OTHER AUTHORIZED AGENT <br />If APPLr wriS not the Burg PARTY. proof of authorization to sign is required <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property Dated at the above site address, hereby authorize the release of <br />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 <br />as it is available and at the same time it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY: <br />EMPLOYEE # <br />DATE: <br />ASSIGNED T0: <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />Amount Paid Payment Date <br />Payment Type <br />Invoice # <br />Check 9 <br />Received By: <br />