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C( L1TY ID d•' <br /> i <br /> EsFalon Unified School District - Bus Garage ILtINg ►ARFw 7 7y / N <br /> TACILITY NAME �] � <br /> SITE ADDRESS 11 L,6 N. Stanlslaus �� C,/,J�� bt -� <br /> city EsIWon __ CA zip 95320 CHU <br /> n Unified School District SILL <br /> EshhaloINGPARTY Y / N <br /> OVNFA/Ot'ERATOR N -- <br /> DDA Noll applicable _ PHONE MtI 20g )_83$_-3591 % <br /> ih <br /> ADDRESS 1500 E Yosemite Avenue PHONE 02 ( ) <br /> CITY ESCalon _ STATE _ f.A ZIP 95l7n - <br /> ArN RLard Use Applicetlan I <br /> OOS Diet Location Code <br /> CONIRACTCA and/or <br /> SERVICE REOUESTOR Jim Thorpe Oil Inc rRnuNG PARTT Y / N <br /> ODA Rich-Mart Construction _ PHONE /i c 709 )368_•_6775 <br /> MAILIND•ADDRESS P bI 601-357 FAX g <br /> C17Y LoUi STATE ra zip 95941-0397 <br /> i <br /> I <br /> MILLING ACKNOULEDGEMENft i, the undersigned owner, operator or agent of Ott", acknowledge that all site and/or project apecftle <br /> PIIS/END hourly chsrgesl asocleted with this facility or activity will be billed to the party Identified as the SILLING PARTY on <br /> Pft" 1 of this form. <br /> i <br /> I Aleo certify that 1 eve prepared this application and that the work to be porformed will be done In accordance with all SAN <br /> JOAQUIN COUNTY Ordlna4e Codes and Standards,_,state and redaral lows. <br /> APPLICANT'S SIGNATURE . <br /> F1ic ae ar er <br /> Title: AdministraItor of Operations Date- 5/_11Q/94 <br /> AII1HDRIZATId1 TO RELEAGE INFORMATIONI In sddltlon to the above, when applicable, 1, the owner, operator or agent of acme, of <br /> the property located ask the above site address hereby authorlle the release of any and all results, geotechnical data and/or <br /> envirorv*ntal/site assessment Informatlon to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time It Is provided <br /> t-o nk or my representative. <br /> 77 77 <br /> Nature of Service Repue'e/t t { '1' /�'»'�-�' -0`' ' Service Code 3� <br /> AAsigned to Mr /C F�L!'L Employee M Date ^,•_J / <br /> Date Service Completed _/ / further Action Requiredt T / N PROGRAM ELEMENT a 3 • Y 0 <br /> Fee Amount - Amount Paid Date of Payment Payment Type Receipt N Check 0 Recvd By <br /> N�� L�e 5�r1 q X39"(% <br /> MIS _/_J_ SUPV __,_/____•_f� ACCT �/ /Z. 1,_L UNIT CLK _/_J� <br />