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SERVICE REQUEST L/ il h ,''jl (SERVREO) Revised 8/23173 <br /> �7 Q' c7 � <br /> FACILITY IDR RECORD 1D1 I �' -� INVOKER <br /> rarlutr Ft— —�WLE SR AUTO BODY/ ROY FOWLER BILLING PARTY ir) / N <br /> 405 N. EDISON STREET <br /> 511E ADDRESS <br /> STOCKTON95203 <br /> � CIYY CA 21P � <br /> rAMFR/nPFRATOR SAME AS ABOVE BILLING PARTY Y / N <br /> DBA PHONE 01 ( ) <br /> ADDRESS PHONE M2 ( ) <br /> CITY STATE 21P <br /> APR R 1E ROS <br /> Use Appl lcation M <br /> BOS Diet Location Code <br /> RTRACT CRR and/Or <br /> USERVICE REQUESTER, SAME AS ABOVE <br /> SF RVI CF RFolNES10R BILLING PARTY T / N <br /> DBA Ili) \1 ""s _ PHONE Rl ( ) <br /> MAILING ADDRESS U -r 9(1l" FAX R ( ) <br /> CITY �A STATE �y� ilp <br /> FN�IR�NMI SERN1 A,l <br /> Pr=y - <br /> RII.LING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or protect specific <br /> PIIS/EHO hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br /> Pogo 1 of this form. <br /> I nlso certify that I have prepared this &pO()cstIo7 a# that the work to be performed will be done In accordance With all SAN <br /> JOAQUIN COUNTY Drdlnarxe Codes and rds Stat ederal laws, p�itpp <br /> APPLICANT'S SIGNATURE <br /> JUI..,NJIN OJUNTy <br /> '=NVIgONFAE/ pF/H5 <br /> Title: 041NER 04 MARCH,, 2000 <br /> D y-,, <br /> AUIHOR12AtION To RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all 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. <br /> Nature of Service Request! e 1MIL, 4«� Service Code <br /> Aaslgned to �T �L-- Employee N �,/, Date / / <br /> Dote Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 4 <br /> ree Arrant Amount Paid Date of Payment Payment Type, Receipt R Check R Recvd By <br /> 06 �iys <br /> RFNS / / �--� SUPV _/__/_ ACCT _/ / UNIT CLK _/ /_ <br />