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SERVICE REQUEST — (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # / 'j INVOICE # <br /> FACILITY NAME Woolsey Oil Cardlock BILLING PARTY Y / <br /> SITE ADDRESS 930 East Victor Road <br /> CITY Lodi CA ZIP 95240 <br /> OWNER/OPERATOR Woolsey Oil , Inc BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS 166 Frank West Circle PHONE #2 ( ) <br /> CITY Stockton STATE CA zip 95206 <br /> p APN # Lard Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR .Johnson Petroleum Construction BILLING PARTY Y / �N <br /> DBA PHONE #1 ( 209 878- 6834 <br /> WILIWG ADDRESS P . O . Box 7169 FAX # ( 916 ) 878 - 6438 <br /> CITY Auburn STATE _fig_ zip 95604 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 A1?AA4 'PARTY on <br /> Page 1 of this form y l°Yj(?.""«f'r, <br /> 1 also certify that 1 have prepared this application and that the work to be performed will be done irt)s(GrJar8e19@F atl SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, a f dernt laws. <br /> SAN JOACUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> APPLICANT'S SIGNATURE F.NV1RONWKr,- 4-4i-XI In, . <br /> y mo14— <br /> Title: p_..Yl+ 10l� Date: <br /> AUTHORIZATION TO_RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 infonmation 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: Service Code <br /> Assigned to rtLFn1C) Employee # _ Date <br /> Date Service Completed / / Further Action Required: Y / NPROGRAM ELEMENT -3 (i3 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS _/ / SUPV _/ / ACCi <br />