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(EN 00 61) Revised 8/23193 <br />SERVICE REGl1EST <br />I RECORD to N <br />FACILITY ID A <br />8111140 PARTY Y / N <br />FACILITY NANE Teresi Trucking <br />SITE ADDRESS 900 1/2 E. Victor Rd. <br />clTr <br />Lodi I <br />CA zip 95240 <br />Bt LLINO PARTY � / N <br />mHER/OPERATOR Teresi Trucki <br />PHONE NI (2n4 I'i�18.— �/—�-.2— <br />DBA <br />PHONE M2 ( ) <br />ADDREss900 112 E. Victor Rd <br />STATE C_ ZIP 9q240 — <br />CITY Lodi <br />— APN R p Lend Use Appltestton M Bos Dist I Location Cak <br />CONTRACTOR andlor I BILLING PARTY Y / <br />SERVICE REOUESTOR Jim Thorpe 011, Inc. <br />PHONE N1 ( goo ) R44- 6175 <br />DBA <br />FAX If ( 209 )36.$ '.M <br />HAILING ADDRESS P. 0. Box 357 <br />CITY Lodi, STATE CA zip 95241-0357 <br />BILLING ACKNO(ILEDGEMM! I, the undersigned owner, operator or agent of acme, Acknowledge that ail Atte and/or project specific <br />DNS/EHD hourly charges associated with this facility or activity will be billed to the party Identified As the BILLING PARTY on <br />Rage 1 of this form. p yMEuT <br />yr�pp�}_1VW7- D SAM <br />I also certify that t have prepay �s app,iced//CT / // at the work to be performed will be done 1n et Pik4.Ei1✓� Q <br />JUAGUIN COUNTY Ordinance Code e 5 rdards and deral laws. OCT 1995 <br />APPLICANT'S SIGNATURE JAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />Title: ContractQr Date: 111/27J95 -- o- ! TAL HEALTH DIVISION <br />AUTHORIZATION To RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br />the property located at the above site address hereby authorize the release of any aid all results, geotechnical data end/or <br />environmental/site assessment information to SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />it is available end at the same time it is provided to we or my representative. <br />. t\ 11 --h n_ n.,v.rt-on Service Code <br />Nature of service Request: c �1 <br />Assigned to uh <br />n Employee N '( Ciy� Date <br />Date Service Completed ,_/ / Further Action Required: Y / N PROGRAM ELEHENT � 3 O��— <br />