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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> �,�/1/, /` INVOICE # <br /> FACILITY 1D # RECgID ID # Vv 3 (/ <br /> FACILITY NAME Don Rodgers BILLING PARTY Y / ;N.' <br /> S <br /> SITE ADDRESS W. Charter Way <br /> clrr <br /> Stockton, CA zip 95206 <br /> OWNER/OPERATOR Don Rodgers BILLING PARTY CY / N <br /> DBA PHONE #1 (209 ) 465 -7515 <br /> ADDRESS 11900 S. Union St. PHONE #2 ( ) <br /> CITY Manteca, STATE CA zip 95336 <br /> APN If Lard Use Application # <br /> BOS�D ist Location C i <br /> CONTRACTOR and/or Jim Thorpe Oil, Inc. � BILLING PARTY Y / <br /> SERVICE REOUESTOR <br /> DBA PHONE 01 ( 2.0q) 368 ' C)17 <br /> HAILING ADDRESS P.O. Box 357 FAX # ( (�) 36R - 189,1 <br /> CITY <br /> Lodi, STATE CA ZIP95241-0357 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site 1j ific <br /> PNS/END hourly charges associated with this facility or activity will be billed to the party id SSI on <br /> Page 1 of this, form. <br /> I also certify that I have prepar hi appIIcatil and t the work to be performed will be d irF3�t or2degee1dt#h ell <br /> JOAQUIN COUNTY Ordinance Cod and rndards, rat laws. (A1- <br /> NE <br /> --�^'-v'4?0NMj/SERVICES <br /> APPLICANT'S SIGNATURE ESM <br /> Centra for 1/23/96 <br /> Titte: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located At the above site address hereby authorize the release of any and ell results, geotechnical data and/or <br /> environmental/site assessment Information to SAN JOAQUIN 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 my representative. l <br /> Nature of Service Request: �(/1-'L vL�-�} Service Code <br /> Assigned to _ )e_ee ?� @A�• Eaptoyee # —CM Date <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment type Receipt # Check # Recvd By <br /> SUPV _/_/_ ACCT _/_/_ _ Ur)IT <br />