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/"YJ/—�� y:U'VJIiM rrcurl ' <br /> -�/� SERVICE REDIA:ST (EN 00 61) Revised 3IZ3193 <br /> FACIL I7T IDM t 11 RECORD IDM <br /> V <br /> BI SLING PARTY Y` / N <br /> FACILITY NAME S <br /> SIZE ADDRESS II 'jy t ' <br /> C1 TY Li 1AtjP.�l CA IIP �523(d <br /> OWNER/OPERAIOR Y k U 'T r RiLANG PARTY / H <br /> DNA <br /> PHONE M1 <br /> AODRE SS 0fA}. IJO _ T-7©3j/& PHONE M2 ( ) <br /> CITY STATE L'� 27P <br /> APN s and LUbe Am .tint A <br /> DOS Disk Location Coda <br /> CONTRACTOR and/or - ^ ^ <br /> SERVICE REOJESTOR _ J 1. BILLING PARTY Y <br /> ���tO / N <br /> ORA NE((� PROfl ( �j ) - ,f <br /> HAILING ADbRESS 17i�7 S 7� �r FAX If ( ? I <br /> CITY �W SIATE ` UP <br /> RULING ACKNOWLEDGEMENT! 1. the Undersigned owner, operator or agent of Snag, acknowledge that all $ite andlor project specific <br /> PHS/END hovrty 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. <br /> I also certify that 1 have prepared this apPUCROW and that the work to be performed wilt be done in 4049rdance with all SAN <br /> JQ"IN COLMTT Ordinanec S /+girds, state and Federal Laws. - <br /> APPLICANT'S SIGNATURE <br /> Title- /,Jul. JCl.1 G'J �(n� VW•Y'� Date. <br /> At1THOR12AT1ON TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of sme,, of <br /> theproperty Located at the above site address hereby authorize the release of ary and all results, geotechnical data and/or <br /> .irorwntal/site assessment information to SAN JOAOUIN CCUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as Soon as <br /> it is Wei table and at the some time it is provided tow or Ah' reprelehtat lve. <br /> Service Code <br /> Notwe Of Servicpe RRaglweest:/_� <br /> Assigned to I/t A ��,,,i 1 1 i(� l I— Y-n" Eaployee k Date <br /> Date Service Ceaplated _I_._! Further Aetfart RaRlired- T / N PROORAN ELEMENT <br /> I,- 7T <br /> ee ANd,n[ A m nt Paid Date of Pa Mart Pays t Type Receipt M Check 0 Recvd By <br /> -i <br /> �V <br /> X07-07-1997 O9:5GAM P•02 <br />