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1 SERVICE REQUEST al <br /> (SERVREQ) Re'slsed 8/23/9I <br /> jY ID`s - RECORD'ID N <br /> R 46 <br /> INVOICE N r <br /> ' Market <br /> Y NAME J & L M - , <br /> GILLINQ PARTY <br /> DRESS8115 South ETDorado Street <br /> CITY French;Camp' 95231 ' <br /> CA zip <br /> RATOR James' Fisk <br /> BILLING PARTY <br /> DBA J & .L` Market <br /> PHONE N1 209 982,_ 0897 <br /> DRFss8_115 'South `El Dorado''Street <br /> PHONE #2 ( ;209 <br /> wi ;209 <br /> ( <br /> fITY 'FrenCh Call] " v' . ti ; <br /> STATE Ca zip 95231`, r, <br /> —Land Use Application <br /> BOS Dlet Locat�ton Code <br /> OR and/or <br /> FOUESTOR _L, 11te-__LV__�n.-Jac Qn_ 'Attl1 T11T1 G112SO11 <br /> BILLING PARTY .':_ Y <br /> DBA <br /> PHONE N1+ 461 <br /> 209 s. r <br /> ( � <br /> )DRESS <br /> 2- 36=T-e p11t FAxN (2 <br /> 'CITY 6n STATE` <br /> ?IP <br /> I <br /> ACKNOWLEDGEHFNT: I, the tndersIgned owner, operator or agent of same, acknowledge that -ell site endJor protect Specific > <br /> hairly charges a'ssoclated with this facility or activity will be bjlled to-the p�rty;Identlfied ss'the BILLING PARTY on <br /> ;1 <br /> of 1 t <br /> -------------------- <br /> of this form, t <br /> certIf y that I have prepared this afpticatlon and that the work to be performed will be done In accordance with ell SAN <br /> CCUNTY Ordinance Codes` snd Standards, State and Federal laws. <br /> T�S''SIGNATURE <br /> Date: 4 <br /> DIZAT I ION 10 RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator.or agent of same, of <br /> perty located at the above site address here <br /> kk by authorize the release of any end all results, geotechnlcaC date erxi/or 7 <br /> V"ntal/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as - <br /> Rvallable and at the same time It Is provided to m,! or my representative. <br /> �e of Service Regiest: <br /> ned to Employee N / <br /> Service Completed � � _. . �' Date _� ...::'t J__ �- <br /> J_ / Further Action Rec�iired:i Y / N PROGRAM ELEMENT <br /> Amount Pa{d' Date !of-Payment ` Fe ' <br /> yment'1yP! Receipt N r' ri:Check Nip " Recvc€ Rv <br /> c <br /> — s u <br /> ACCT 'f .r ..J j", )� <br /> Er r LNIT`L t K <br /> A(00 <br /> ' ,..est _ ��� .4. _ia a�:t. 4_.L�:'Qi•��� r?Xr""f';L`�,`Y,- ��, <br />