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�,d <br />SERVICE REQUEST is <br />Type of Business or Property <br />Communications <br />BILLING PARTY XX <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER/ OPERATOR <br />AT&T <br />BILLING PARTY _. <br />FACILITY NAME <br />Kvaerner Aronson, Inc. <br />I SITE ADDRESS <br />110 Wg-sf er Street N-imber <br />Direction <br />West Turner Rd Street Name <br />Tvpe Suite: <br />Mailing Address (If Different from Site Address) <br />11297 Colonia Rd. <br />CITY <br />TQdJ <br />STATE ZIP <br />Ca <br />PHONE #1 EXT. <br />( ) <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />BILLING PARTY XX <br />Kvaerner Aronson Inc. <br />BUSINESS NAME <br />PHONE # Ezr. <br />Kvaerner Aronson, Inc. <br />l l:c-rec- <br />(916 631 - 1646 <br />MAILING ADDRESS <br />FAX # <br />11297 Colonia Rd. <br />I <br />(91Q 631-0437 <br />CITY Rancho Cordova <br />L_ <br />STATE Ca ZIP95670 <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 />also certify that I have prepared this <br />FEDERAL iaw'S. <br />APPLICANT <br />PROPERTY / BUSINESS OWNER <br />and that the worts to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />DATE: <br />Fi GPERATOP. / MANAGER x OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING 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 located at the above site address, hereby authorize the release of <br />any and all , esults, geotechnical data and/or environmentaVsite 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 />19 <br />COMMENTS: <br />ppq�y�� <br />fes! t1 M E N <br />SEP 2 2 1998 <br />SAN JUAUUIN CC.VN1Y <br />PUBUC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISIOr4 <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVEDBY <br />EMPLOYEE$. <br />EMPLOvEE`vv <br />ASSIGNEDTO: C <br />EMPLOYEE#: b (0 <br />`Lf <br />DATE: <br />111 <br />Date Service Completed (if already completed): <br />SERVICE CODE: PIE: <br />Fee Amount:��� <br />Ob <br />Amount Paid <br />Payment Date , �%& <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />