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F:1 <br /> ` -, ♦:'€ <br /> SERVICE REQUEST (SERVREQ) Revised 8/23/93 <br /> FACILITY ID 0 RECORD iD N INVOICE 0 <br /> rACILiTY NAME J & L Market <br /> BILLING PARTY / N <br /> SITE ADDRESS 8115 South E1Dorado Street <br /> CITY Frenth Camp CA zip 95231 <br /> nJNFR/OPERATOR James Fisk BILLING PARTY Y / N <br /> DBA J & L Market PHONE N1 ( 209 ) 982 _ 0897 <br /> ADDRESS 8115 South E1Dorado Street PHONE CM2 ( 209 ) 982 -0897 <br /> CITY French Camp STATE Ca zip 95231 <br /> -APH # —Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SFRVICE REQUESTOR Elite IV Contractors Attn: Tim Gipson BILLING PARTY Y / ®. <br /> DBA PHONE #1 (209 ) 461 -6337 <br /> HAILING ADDRESS 2736 !e@pAp flritirpo Unit iicii FAX R (2II9 ) <br /> CITY StnrLtnn STATE Ca` zip 9520 - - <br /> BILLING ACKNOWLEDGEMENT: i, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/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 nlso certify that 1 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 Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE a ,. <br /> J <br /> Title:- oWi pr 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 date 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: Service Code <br /> Assigned to Employee Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Peid Date of Payment Payment Type Receipt '_ Check N Recvd .By <br /> RENS / / SUPY _/ /. ACCTt)NIT CLK / s- <br />