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SERVICE REQUESTnn (EH 00 61) Revised 8//23/93 <br /> FACILITY ID # RECORD ID # Vv 3 V� INVOICE # �'�[� <br /> FACILITY NAME Corral Hollow Sanitary Landfill CVJVV BILLING PARA MENT/ 444 <br /> SITE ADDRESS Corral Hollow Rd. and I 580 <br /> IAN 2 5 100nS <br /> CITY Tracy, CA CA ZIP 95376 PUBLIC HEPIT� ` ';NTY <br /> r� J <br /> ENVIRON <br /> PUBLIC <br /> E f FRVICES <br /> OWNER/OPERATOR San Joaquin County ,ulb\�" 1/L9 L) BILLING PARTY Y / N <br /> DBA <br /> && K. Wx1§9# 1 � F PHONE #1 (209 )468- 3257 <br /> ADDRESS 222 E. Weber Rm.675 PHONE #2 ( ) <br /> CITY Stockton, STATE CA zip 95202-2777 <br /> rAPN # P Lard Use Application # BOS Dist Location Code <br /> CONTRACTOR and/or I <br /> SERVICE REQUESTOR Jim Thorpe Oil, Inc. BILLING PARTY / <br /> DBA PHONE #1 (209 )368 _ 6175 <br /> MAILING ADDRESS P.O. BOX 357 FAX # (209 11368 - 1851 <br /> CITY Lodi, STATE CA Zip 95241-0357 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site <br /> arid/or ppprooject s cific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the pity identifim [1l aIING PA TY on <br /> Page 1 of this form. <br /> �. p nI 1 yip <br /> I also certify that I have prepared is application and shat the work to be performeQ witL be done-J N,11,3%9� th at SAN <br /> JOAQUIN COUNTY Ordinance Cod a tanda , e rat laws. <br /> ly <br /> v <br /> APPLICANT'S SIGNATURE N� - <br /> Title: Contractor Date: 1/15/96 <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 att results, geotechnical data and/or <br /> environmenta L/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. <br /> Nature of Service Request: Service Code <br /> Assigned to ►✓Ut D-41r� Employee # Date <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT 2-3 <br /> Fee Amount Amount Paid Date of Payment Payment Receipt # Check # Recvd By <br /> RENS �� / SUPV _/_/_ ACCT ' _/_ / - `" UNIT CLK _/_/_ <br />