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r, <br /> SERVICE REQUEST (EH 00 60 Revised 8/23/93 "< <br /> INVOICE / <br /> EE / <br /> FACILITY NAME Star Building Systems siLL1N0 PARYY LY' / N <br /> SITE ADDRESS 12101 E. Brandt Rd. <br /> CITY Lockeford, CA 95237 CA Zlv <br /> Same as above aILLING PARTY Y / N <br /> OWNER/OPERATOR <br /> PHONE N1 ( 209 727 'SS.(14 <br /> DBA <br /> PHONE s2 ( ) <br /> ADDRESS <br /> CITY STATE ZIP <br /> APN M p Lard Use Application R <br /> IROS Diat Locat ion Code <br /> CONTRACTOR and/or <br /> SERVICE REDUESTOR Jim Thorpe Oil, Inc. KILLING PARTY Y / <br /> DBA PHONE #1 ( 7.nQ )_-JCR 6175 <br /> HAILING ADDRESS P.O. 'BOX 357 FAX # (-2O <br /> CITY Lodi, sTATE CA ztv 95241-0357 <br /> BILLING ACKNOWLEDGEMENT: 1, the Undersigned owner, operator or agent of sAme, acknowledge that ell alts and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party Identified 88 tjtg181d1140'44ifY on <br /> Page I of this, form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with sit SAN <br /> JOAQUIN COUNTY Ordinance Code tandards Federal laws. <br /> i <br /> APPLICANt'S SIGNATURE <br /> Title: Contractor Date: <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 date and/or <br /> environmental/site assessment Information to SAN JOAQUIN CCUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as II <br /> It Is available and at the same flim It Is provided to me or m/ representative. i <br /> Nature of Service Request: ��WLi 2�i`fyv� service code <br /> Assigned to IE/�Y/, ��'✓✓E,-�' - Employee # Go-b Date y_/ <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAH ELEMENT % ,L <br /> Fee Am t Amount Paid Date of Payment Payment Type Receipt M Check R Recvd By <br /> RENS J / / `jL SUPV _/_/_ ACCT _/_/ UNIT r- .. <br />