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SERVICE REQUEST `„i (SERVREO) Revised 8/23/91 <br /> FACILITY IDM RECORD ID M D0q y INVOICE I <br /> PIEDMONT LUMBER & MILL CO., INC. <br /> rACILITY NAME RILL INg PARTY Y / <br /> SITE ADDRESS 7777 WEST ELEVENTH STREET <br /> TRACY CA zlP <br /> nIMFR/OrERATOR 95376 <br /> CITY <br /> PIEDMONT LUMBER & MILL CO., INC. BILLING PARTY / N <br /> DRA PHONE 01 ( ) <br /> ADDRESS 395 TAYLOR BOULEVARD SUITE 225 PHONE 02 (510 1 674 _ 8770 <br /> PLEASANT HILL CALIF. 94523 <br /> CITY STATE ZIP <br /> APR M --i Lard Use Application N <br /> r <br /> TICS Dist Location Code <br /> CONTRACTOR mid/or <br /> SFRVICE REOUESTOR JAMES J. HOBLITZELLBILLING PARTY Y / <br /> DRA PHONE Nt ( 209 > 943 - 7793 <br /> NAILING ADDRESS BOX 30331 FAK M ( 209 > 943 - 2811 <br /> CITY STOCKTON STATE CA ZIP 95213 <br /> PILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified se the BILLING PARTY on <br /> Page 1 of this form. <br /> I nlca certify that I have prepared this application and that the work to be performed will be In accordance with all SAN <br /> JOAOUIN CCUNTY Ordinance Codes and Standards, State and Federal laws. ^5 G <br /> APPLICANT'S SIGNATURE : X / ' DMD/1/J'L.!/.tq/fc�/L I� �IGG CO, �,K. qy• GS`-f .I�l�' <br /> Title:l� �J�lff)L tG//td7vr;/9'L O��->`iC.Y�t_ Date:k S-/hy/fj _ <br /> AIITHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owneF;�apehatoN=orNgerlt�df;Ilie�dvl�10N <br /> the property located at the above site address hereby authorize the release of any and ell results, geotechnical data and/or <br /> environmental/site assessment Information to SAN JOAOUIN 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: G1�� �Ltn\Oy6�� Service Code �Yy <br /> Assigned to Employee N R(n Fp _ Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT .�S{�- <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By <br /> a3y, oc� � <br /> RFNS _/ / SUPV / / ACCT _/_/ <br /> ` <br /> FAGE ONE �, <br />