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SERVICE REQUEST (EN 00 61) Revised 8/23/43 <br /> RECORD IDA i INVOICE N <br /> FACILITY to A f ,- <br /> Connell Motor `Irupk Co. , Inc. SILLING PARTT Y' ! t <br /> FACILITY RAHN <br /> 2211 N. Wilson Way <br /> SITE ADDRESS <br /> erTr <br /> Stockton, CA zap 95205 <br /> Connell Motor Truck Co. , Inc. BILLING PARTY / H <br /> t)I1FIE R/OPERATOR <br /> PHONE A 1 (,209)10�411 <br /> beA <br /> 2211 N. Wilson Way PHONE N2 <br /> ADDRESS <br /> Stockton, CA 95205 <br /> city <br /> STATE CA , �-- <br /> APN A Lend Uee ApplCostlon A Location Code <br /> Boo Dlst <br /> CONTRACTOR and/or jim Thorpe Oil, Inc. BILLING PARTY <br /> SERVICE RFOUESTOR <br /> PHONE Al (_209 �^368 _ 6175 <br /> DBA <br /> P.O. Box 357 FAX N ( 209)_368 : 1851 _ <br /> MAILING ADDRESS <br /> Stockton, STATE <br /> 95241-0357 <br /> STATE YIP <br /> CITY <br /> BILLING ACKNOITLEDGENEHTt I, the undersigned owner, aperetor or agent of same. acknowledge that all site End/or project specific <br /> pill/Ello hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br /> peg@ 1 of this form. <br /> I e{eo certify that 1 have prepared this application and that the work to be performwd will be dof#Aff <br /> * with all SAN <br /> JOAQUIN COUNTY Ordinance Codes ondar to Federal lows. RISC ER Pr.i <br /> APPLICANT'S SIGNATURE <br /> President 4/22/95s <br /> Onto: UIJIjY Vit''. <br /> Title: PUBLIC HEALTH SEFWItES _ <br /> ENVIRONMENTAL HEALTH DiM <br /> AU1110IIIATION to RELEASE INFORMATION1. In addition to the above. when applicable, OW <br /> Ar,the aar, operator or agen i1�#sma, of.L <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical'date and/or <br /> AOUIH COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> envlrormentel/elle seeassment information to SAN IO <br /> it Is available end at the soma time it Is provided to one or my representetive. <br /> Nature of Service Requeett <br /> �� i C Service Code <br /> Assigned to <br /> r { ` Employee N C� •� Date / <br /> •�~ ` � • <br /> Data service Completed _/-1 Further Action R"I reds V / NPROGRAM ELEMENT IIS <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt A check N ` ]R*cvd By <br /> ., „� St7PV r�—/ ACCTT' 7/ /_ UNIT CLK �/ / <br />