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SERVICE REQUEST (EN 00 61) Revised 6/23/93 <br />FACIL tY 10 N % RECORD ID 11111 <br />- <br />INVOICE N <br />fACILI tY HANE Multi — Day Enterprises J BILLING PARTY Y / <br />SITE ADDRESS <br />1444 N_ El Dorado St <br />CITY Stockton, CA zip 95202 <br />EWN/OPERATOR Multi — Day Enterprises BILLING PARTY (Y / N <br />PHONE 01 <br />DBA <br />ADDRESS 351 N. Walnut Rd. # 15 PHONE 02 ( ) <br />E <br />city Turlock STATE CA <br />{p Lend Use Application N <br />CONTRACTOR and/or <br />SERVICE REGUESTOR _ Jim Thorpe Oil, Inc. <br />DBA <br />MAILING ADDRESS P.O. BOX: 357 <br />CITY Lodi <br />STATE CA <br />zip 95380 <br />BOS Dist Locet ion Code <br />BILLING PARTY Y / <br />PHONE N1 ( %I7Q )_118._' 6179 <br />FAX N <br />zip 95241-0357 <br />( 204 ) 368 <br />s/jC.uyr Yom->`r� <br />BILLING ACI(NONLEOGEMENTt 1, the undersigned owner, operator or agent of SAM, acknowledge that all site and/or pro Ocl,_SPeeifla <br />DHS/EHD hourly chargee associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br />Page I of this, form. " .3 1"�9�' <br />I Also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY ordinance Coded a�-fCendarlds,-"e aro�`Federal laws. <br />APPLICANT'S SIGNATURE : <br />Title: Contractor Date: /O / L/� _ <br />a <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 all results, geotechnical data and/or <br />environmental/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION es soon as <br />It In available and at the same time it is provided to me or my representative. <br />Nature of Service <br />Reque(s�ts Service Code <br />Assigned to 1 (,O�'� Yi `^'�.1Ji� Employee N 0 in C O Date <br />Date Service Completed _/_/_ Further Action Required: Y / N PROGRAM <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt N <br />Check N <br />Recvd By <br />ACCT <br />q a <br />& . <br />�0 3 sb <br />:INIT <br />�� s�o <br />`)=goz-- <br />RENS/ <br />lam/ <br />Z <br />SUPV <br />__/_/_ <br />ACCT <br />_/_/_ <br />___ <br />:INIT <br />