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SERVICE REQUEST <br />INVOICE N <br />(EN 00 61) Revtaea o..-. <br />RECORD ID N <br />FACILItY ID N <br />ING PAR1 <br />Y <br />Y / N <br />FACILITY NAME TBILL <br />eresi Truckin <br />SITE ADDRESS 900 1/2 E. Victor Rd. <br />CA nP9524_-- <br />elTr Lodi <br />BILLING DARtY =/ N <br />OM1ER/OPERATOR Teresi Trucki <br />_ �, ,» <br />PHONE N1 (�nq )—�8-- �------ <br />DRA <br />DNONE 02 ( T -�----- <br />ADDRESs900 1 2 E Victor Rd <br />STATE -LL— zip <br />cITYLodi <br />p Lard Use Appl(cetlon N <br />nos Dl at Lecetiw+ Code <br />— APN N <br />I <br />BILLING PARTY Y / <br />CONINACTCR end/or Jim ThorPe Oil, Inc. <br />SERVICE REQIIESTOR <br />fl %F <br />DeAFAX <br />R ( ��=-'-�209 18-51 <br />y.c_>-+�-—�— <br />HAILING ADDRESS P. 0. Box 357 <br />95241-0357 <br />Lodi, STATE CA zip <br />city <br />opa= ,.. 11 alta std/or protect specific <br />Identified <br />will be billed to the party idents fled es the BILLING PARTY on <br />NILLINO ACKNOULEDOEHENT: 1, the undersigned owner, operator or agent of Bete, oto th party <br />DNS/END hourly charges associated with this facility or activity <br />Page 1 of this farm. <br />to be performed <br />will be done in accordance with ell SA <br />I also certify that I have prepay thisS/" applic°tie nd �de�elh the <br />lOAOUIN COUNTY Ordinance Code e S erda, <br />— <br />APPLICANT'S SIGNATURE a <br />Date: <br />Title: Contra or <br />o rotor or agent of sane, of <br />rt located et the above site address hereby authorize the release of any aril all results, geotethnitel date std/or <br />AUTHOR KATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, <br />the property <br />environmental/site <br />assessment Information to SAN JOAaUtN CUINTY PURALTHSERVICES ENVIRONMENTAL HEALTH DIVISION es soon as <br />it is available end et the same tine 1t is provided to me or myrepresentative <br />Sery Ce Code <br />Nature of Servlet Request[ — / <br />Date _/ <br />Employee N <br />Assigned to <br />/ <br />Further Action Required: Y / N PROGRAM ELEMENT <br />Date Service Cospleted _/ �-- <br />Date of Payment Payment Type Receipt N <br />Check N Recvd Ry <br />Fee Amazed Amma,t Paid <br />UNIT CLK _./--/--- <br />/ ACCT <br />RENS / / SIRV / <br />