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SERVICE REQUEST (SERVIIEO) Reviled 5/13193 <br /> fACILITY ID N RECORD IDN �� �, BILLING PARTY o '/ N <br /> PAcltlTt NAME , RAY FARMER ENTERPRISE, INC. <br /> silt ADORE1111 240 N. California Street <br /> Stockton CA IIP <br /> DtINEA/oPERAIdt RAYMOND E. - FARMER BILLING PARTY Y / N <br /> RAY FARMER ENTERPRISE, INC. tllONfi #1 209 952-3260 <br /> AODREss 3810 Fourteen Mile Drive, Stockton, CA •-0 'g t 209 477x9993 <br /> �ItY Stockton STATE CA iip 95219 <br /> APR A Census --------- BIDS Dist Location Code city code ------ <br /> CONTRACTOR end/or Jim Thorpe Oil Inc. <br /> SERVICE REQUESTOR BILLING PARTY Y I(") <br /> DBA Rich-Mart Construction PHONE 01 ($00 i 844 - 6175 <br /> HAILING ADDRESS P.O. BOX 357 FAx N (Z09 > 368 1+851 <br /> CITY Lodi, STATE CA IIP 95241-0357 <br /> 0W ING AUNCt1LEDGEMENTs 1, the undersigned owner, operator or agent o/ same, acknowledge that all site and/or project specific <br /> PHS/END hourly charges associated with this facility or activity wltt be bitted to the party Identified as the,BltLING PARTY on <br /> Page I of this form. <br /> I also certify thet I have prepared this ap�licatlon and that the work to be performed will be done In accordance with all SAN <br /> JOADUIN COUNTY Ordinance Codes and tardards, State Feder to s' <br /> AP6tICANI'll SIGNATURE J. C � <br /> Iltlet, - pxeg;, pn.t oatetL_September 16, 1994 s <br /> AUTHORIZATION TO RELEASE INFORMATION: In additlon to the above, when applicable, 1, the owner, operator or agent of some, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical date and/or <br /> environmental/site assessment Information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It Is available and at the same time It is provided to me or ay representative. <br /> Nature of Servlee Requestl Service Code <br /> Assigned to _ -_ ti �•� Emptoyee N Date 9 <br /> i <br /> oste service Conpleted J Further Action Required: Y J N [PROGRAM ELEMENT . KID <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By <br /> RENS / / SUPV �JJ / ACCT _/ / UNIT CLK <br /> , <br />