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I St'$rd t � <br /> SERVICE REQUEST ! (EM 00 61) Revised S/L1/41 ti <br /> FACILItY IDI RECORD ID `�) <br /> FACIIItY NAME Zoya 0. Bryner HILL IND PAR" <br /> �j <br /> if It ADDRESS 704 E. Hazelton St. <br /> city Stockton, CA zlp 95203 II. <br /> I , <br /> Zoya 0. Bryner <br /> UAWNJOPERAIOR SILLINO PARTY Yom/ N <br /> DBA PHONE II <br /> ADDRESS 7 Cheryl Pl. PHONE az t ) I <br /> city Menlo Park, STATE CA zip 94025 <br /> — <br /> Arm I to Use Application I <br /> ir <br /> ROS Diet Location Dada <br /> CONTRACTOR and/or <br /> Jim Thorpe Oil D PARTY Y / <br /> SERVICE REOUESTOR t Inc.. Sllll <br /> � i <br /> DBA PHONE L 9 It M <br /> I� <br /> NAILING ADDRESS P.O. Box 357 _ FAX N 1 2nq <br /> CITY Lodi, STATE CA zip 95241-0357 <br /> SILLINO ACkNONLEDGEMENit 1, the undersigned owner, operator or agent of same, acknowledge that sit eft@ Ord/o1' prefect OpaolflII <br /> 0115/EHD hourly chargee associated with this facility or activity will be bilted to the party identified At the 911,1100 PARfY an Ili <br /> Page 1 o/ this, form. II <br /> I Also certify that 1 have prepared this a llcati and that the work to be performed will be done In occordence with All SAN <br /> I <br /> JOAQUIN COUNTY Ordinance Codes at <br /> ds, ate el levee. <br /> N� <br /> APPLICANT'S SIGNATURE s - , <br /> Titter Contractor Oetet 3/3/97 V <br /> AVIR012AtloN To RELEASE INFORHAT1ONt In addition to the above, when applicable, I, the owner, operator or spent of ease, of <br /> the property located at the above site address hereby euthorite the release of any and ell results, peotechnlcel data erd/or <br /> areirenmentel/alto assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL NEALTN DIVISION N aeon if <br /> It le available and at the same time It Is provided to me or my representative. <br /> Nature of Aervlee Requeetr I A& <br /> I service Code V- <br /> Aselprad to rT tx�y t ,� X� n-U_ Employee / l 3 Det@ <br /> beta Eervies Coe{rteted _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid tat e.o Payment Payment Type Receipt I Cheek I Reovd 9y II� <br /> f <br /> 3 q b Il�� <br /> SUPV _/_/_ ACCT _/_/_ UNIT r" <br /> �Z, �¢a, w-tr��t-�K�i • ���.t.cat�'` tv tsv�,.:. d>tma. :Mn.au�:�J��• cJ�-- - <br />