Laserfiche WebLink
SERVICE REQUEST _, ERVREO) Revised 5/13/93 <br /> FACILITY 1D N RECORD ID 0 <br /> ILLINRTY <br /> G / N <br /> , <br /> FACILITY NAME rG. ✓'(/Ci Clh /')G AID # - 0.57 <br /> SITE ADDRESS / O / t p� eyzz <br /> FAC # <br /> CITY L,tJ l CA ZIP �f— )• ,! # <br /> -- r <br /> OWNER/OPERATOR / F/�S/ /r�'L�/hl> i /h C BILLING PARTY Y / <br /> OBA '7/Q PHONE M1 ( 2�)-'I)-'IT- <br /> ADDRESS <br /> 29J�i <br /> ADDRESS _ // D�./,�I� /OX /2 PHONE #2 ( ) <br /> CITY C�LDGX / STATE ZIP;ZS�y/ <br /> APN N Census ----•---- BOS Dist Location Code City Coda ------ <br /> CONTRACTOR and/or Jim Thorpe Oil, Inc. <br /> SERVICE REOUESTOR BILLING PARTY Y / <br /> OBA Rich-Mart Construction PHONE s1 ( 209 ) 368-6175 <br /> MAILING ADDRESS P.O. BOX 357 FAX N ( 209 ) 368-]851 <br /> Lodi CA 95241-0357 P�AENT <br /> CITY STATE ZIP ner+F_1VED <br /> era ) n 1,004 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge tlFmtPALO&Lte and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party f 6riti'fied as the BILLING.PARTY on <br /> Page 1 of this form. <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and tanclards, ate and Federal laws. <br /> APPLICANT'S SIGNATURE /O <br /> Title: iC/ /1r . lr ,,i re• Date: / 0 <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 and all results, geotechnical data and/or <br /> environmental/site assessment information 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 to me or my representative. <br /> 0 <br /> Nature of Service Request: "�pf��� K /L-,)(,)/.g L / Service Code 3 <br /> Assigned to � /e '��U�N� Employee s Q Date <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> �3 .0� a3ov a�jy� 1 � 73s <br /> RENS _/_/_ SUPV _/_/_ ACCT _ _ UNIT CLK _/_/_ <br />