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1 • ' 1 <br /> r { <br /> SERVICE REQUEST EEN 00 61) RfVlsed 8/23/93 <br /> rACILIIY to N RECORD <br /> mamma <br /> FACILITY NAM! <br /> The City b Lodi' Public Works Dept. <br /> SILLINO PARTY �Y' / <br /> 121 S Hutchins Street <br /> SIIf ADDRESS <br /> City Lodi, CA ZIP 95240 <br /> , <br /> The' City of Lodi, Public Works Dept. SILLINO PARTY <br /> UAIfR/OPEAAIOR <br /> PHONE NI 1 209 ) 333-6,800e.J((54 1 <br /> DBA <br /> 221 W. Pine St. / P.O. Box 3006 <br /> PHONE NZ t ) <br /> ADDRESS <br /> Lodi, STAIN CA ZIP 95241-1910 <br /> lily <br /> APN sI r�lard Uaa Appllost ion / ®� 909 Dist Locatlon Code <br /> co"INACIOR and/or Jim Thorpe Oil, lne. <br /> SERVICE RE011ESIOR P SILLINO PAR <br /> PHONE N1 1 209 ) 368. 6175 <br /> DBA ' <br /> MAILING ADDRESS P.O. Box 357 FAX t 209 ) 368 ;1$51 j <br /> city <br /> Lodi, CA SIAIE ZIP 95241-0357 <br /> BALING ACKNOIILEDGEMENtt 1, the undersigned owner, operator or agent of some, acknowledge that all site and/or project specific <br /> PNS/Elio hourly charges associated with this facility or activity will be billed to the party Identified as the 91LLIN0 PARTY on <br /> Peg# I of this form. - <br /> I also certify that I have prepared this application and that the work to be performed will FM,dar In accordance with all SM <br /> JOAQUIN CO1UNtY OrdinanceCodes ards, St end f rat laws. <br /> APPLICANI'S SIGNAIURE I <br /> President 4/6/98 <br /> Iltle: Onto? <br /> E6 r <br /> AUIIIORIZATION to RELEASE INTORMATIONt. In addltlon to the nbove, when applicable, I, the owner, operator or agent of same, of, <br /> the property located at the above site address hereby suthorlre the release of any and all results, geotsslnical'deta end/ori_:'. <br /> environmental/sits assessment Information to SM JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION tl Soon es <br /> It Is available end at the some time It Is provided to me or my representative. <br /> I <br /> 3-:z <br /> 7' <br /> Nature of Service Requests %��+�- rPi'Yv✓� Service Code <br /> Assigned to '� . Employes N Gn v Date '� /• f�-yam_'.!'' . <br /> Date Service Ca,pleted / / Iurtlurr Action Required: Y / N PROGRAM ELEMENT A,�d. <br /> He Amount Amount Paid Date of Payment Payment Type Receipt / Cheek N Racvd Sy., <br /> yn2_ yo Snz. So ���� <37 - <br /> SUPv —'--/— ACCT —/—/_ UNIT CLR _/_/_ <br />