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FACILITY 10 a <br />RECORD to R <br />FACILITY NAME Henry Hansen Property <br />SIIE ADDRESS <br />City <br />WHER/oPERATOI <br />09A <br />MORES$ <br />City <br />R <br />200 S. Cherokee Lane <br />•. <br />1 . <br />SERVICE REQUEST �,. (EN 00 61) Revised 6/23/93 <br />T�I W I� � "1 INVOICB / <br />�IlLIMO PMTT . Y' / <br />CA nP 95240 <br />I <br />Henry Hansen c/o Right Way, Inc. <br />2120 W. Lodi Ave. <br />•a <br />STATE <br />Lend Use Applleetian a e <br />CONTRACTOR and/or Jim Thorpe Oil, Inc. <br />SERVICE REOIFS10R <br />DBA <br />NAILING ADDRESS <br />CITY <br />P.O. Box 357 <br />Lodi, <br />CA <br />CA <br />STATE <br />BILLiNO PMTT 0, N <br />PHONE al ( 209 1 369 .'733.9 <br />PROW a2 ( 1 <br />ZIP 95240 <br />�I eo9; Dlat Lxatlon Code <br />BILLING PARTY Y / N <br />PHONE at ( 209 )_7.368 .6175 <br />FAX B ( 209 ) 368 : 1851 <br />95241--0357 <br />ZIP • , <br />BILLING ACKNWLEDGEMEN(I I, the undersigned owner, operator or agent of same, acknowledge that all alts and/or prOJect apeclf lc <br />PRS/EG0 hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br />Page I of this form. <br />I also certify that I hove prepared this application and het the work to be perforoed will be daN� �Nith all SM <br />Ju4O IN COUNTY ordinance Codes erd to doral laws. n �' fit• <br />2 3 i99$ <br />ArPLICANt'S SIGNATURE t <br />Contractor6/16/98eN JTH <br />Deter <br />Iltle: ,B, ppl'TH DIV15',> <br />1RpNMENTP1- <br />AUTHORIZATION to RELEASE INFORMAIIONI, In addition to the nbove, when applicable, I, the owner, ope��.Lyrator or agent Of sone,. of <br />the property located at the above site address hereby outhorite the release of any and all results, gooteQMticoI'date ad/or -`v <br />envlro ntsl/site assessment information to SAN JOAaUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION So soon as <br />It la available and at the am" time It Is provided to m or cry representative. <br />Nature of Service Requestt II �//aN.l�— Y--� <br />Assigned to �F�6Wli <br />Dote Service Coopleted <br />Eeployes M I%Db <br />Further Action Required: Y / N <br />service Cods <br />Data_/ <br />PROGRAM ELEMENT Z " <br />He Amount <br />Po. <br />Dote of Payment <br />Payment Type <br />Receipt a <br />Check B � <br />Neevd By <br />//��Am,^,ount iaiid <br />esus <br />1 J 110 1 SLAV I _,__/_ I ACCT I _/__/__ I UNIT CLK I _/_/_ <br />