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SERVICE REQUEST (EH 00 bi) Revised 8/23/93 <br /> [FACILITY ID # RECORD ID # }q S Zc�] INVOICE # <br /> FACILITY NAME My Mini Mart BILLING PARTY Y / N <br /> SITE ADDRESS 1756 N. Wilson Way <br /> Y' <br /> CITY Stockton CA zip 95202 <br /> OWNER/OPERATOR Annette Hoag BILLING PARTY Y / N <br /> DBA PHONE 01 <br /> ADDRESS PHONE #2 f 7 <br /> CITY STATE ZIP <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR Names C. Bateman Petroleum SVC, Inc. BILLING PARTY Y ! N <br /> DBA SEMCO PHONE 91 (209 ) 524 3653 <br /> NAILING ADDRESS 1217 South 7th Street FAX # (20() ) 574_Q9n'� <br /> CITY Modesto STATE CA ZIP 95351 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that i have prepared this application and that the work to be performed will be done Cenrtande�with atl SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standard State and Federal taws. <br /> r' <br /> - APPLICANT'S SIGNATURE : <br /> JUN 4 9 <br /> SAN JOAQUIN COUNTY <br /> Title: Project ManaC1er Date: 5/12/99 PI IRI Ic'"=+':TH SERVICES <br /> ENVIRCNMENTAL 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 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 /> Nature of Service Request: n� '�{ Service Code (d 3 ( ,_ <br /> Assigned to Employee # Date <br /> Date Service Completed / I Further Action Required: Y / NPROGRAM ELEMENT *-- � <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> [RE HS ( �� 7 _/ SUPV �/ / ACCT �/ / UNIT CL)( �! I <br />