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1 { <br /> SERVICE REQUEST (EN 00 61) Repelled S/L1/1haea;+ <br /> _ n <br /> kkclLl + INVOICE R rl 'i°'�•.lc' �'ilii'i;l t h ,i", <br /> tY m� Ecaao 1011 CJ/ ;�� (;�/ <br /> II <br /> tACILItY NAME Tri Star Homes, LLC ell-LING PARTY Y <br /> SITE ADDRESS 1325 N. Corral Hollow Rd. <br /> city Tracy, CA 95736 CA ZIP i <br /> BILLING PARTY / M <br /> MAZER/OPERATOR Tri Star Homes <br /> DNA PHONE e1 (51.0 )8'18—r4Fin <br /> ADDRESS P.O. Box 1056 PHONE S2 ( ) <br /> Alamo, CA 94507 STATE ZIP <br /> CITY i <br /> pAPN 0ito use Application R 1 I, <br /> II BOS Dlet Locet ion Code � <br /> CONTRACTOR and/or i <br /> SERVICE REMIESTOR dim Thorpe Oil, Inc. alttING PARTY Y / <br /> +II <br /> DNA PHONE e1 ( 7)Q ) -16R 6175 . - II <br /> NAILING ADDRESS P.O. BOX 357 FAX 0 ( X)q )-26S 18531 - <br /> clrr Lodi, STATE CA zip 95241-0357 <br /> RILLIRG ACkNO11LEDGENENTI I, the undersigned owner, operator or agent of Same, acknowledge that ell site end/ot project IWI1110 I; <br /> DHS/ERD hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY an <br /> Page 1 of this, form. , .`+ Adfit iN ' <br /> ac��ItrFG. � <br /> I also certify that I have prepared this application and that the work to be performed will be done In ARpOtdRt15! with all S <br /> 997 <br /> JoAau1N COUIItY ordinance Codes ards, State and F ret laws. IYIAT /+ U <br /> -�J SAN JOAU ". <br /> / PIJBLI NFA, -. V�'rJTY <br /> APPLICANT+S SIGNATURE t� �' 'jyV Nr----kTl13E}�ES <br /> �� 5/19/97 r AL HEALTH DIVISIrr,. <br /> Title: Contractor Date: <br /> AUTHORIZATION To RELEASE INFORNATIONt In addition to the above, when applicable, 1, the owner, operator or agent of acme, of <br /> the property located at the c'oove site address hereby authorize the releeSe of any erd all results, geotechnical date end/or <br /> envlrormentel/elle assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ON soon ss <br /> it Is ovellable and at the same time It is provided to we or my representative. <br /> Nature of Servlae Requests Rervice Code <br /> ASSISned !o �- yDSI, s �a �I Eaployee R l�/(o fs' Date 7. <br /> hate Service leted / �'-t / T Cher Action Rcqulredt T) / N PROGRAM ELEMENT _ "� . ._.__..:. ff <br /> 1 <br /> , <br /> Fee Amount Amount Paid Date of Payment Payment Type I Receipt M Check 0 Reaped By <br /> REIS C�/ /,�_ STNV __/_/_ ACCT �`) / / UNIT ni <br />