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USERVICE'REWEST (SERVREO) Revised 8/23/93 <br /> FLITY ID A �— RECORD 10 it INVOICE R <br /> FOWLERS AUTO BODY/ ROY FOWLER <br /> rnrlllTV wAH$ T, •, .•,..,--,--...•.•„_...._ - –, 41LLIN0 PARTY Y / N <br /> 405 N. EDISON STREET <br /> SITE ADDRESS <br /> STOCKTON95203 <br /> CITY CA ZIP <br /> r1Eri1ER/OPERATOR SAME AS ABOVE- BILLING PARTY Y / N yi <br /> DBA PHONE All <br /> ADDRESS PHONE 02 ( 3 <br /> CITY STATE; ZIP <br /> _ArN Land Use Application <br /> BOS Dist Location Code € <br /> rONTRACIOR and/or SERVICE REQUESTER, SAIME AS ABOVE <br /> SERVICE RE.OUESIOR --�. RIFLING PARTY Y / N <br /> j1,Y �. PHONE 01 i ) <br /> DBA <br /> MAILING ADDRESS ,� FAX <br /> CITY STATE <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that nil site and/or proJect.'specific <br /> p115/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Pege 1 of this form. <br /> I nlso certify that I have prepared this app l cat lo a that the work to be performed will be done In accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and rds Stet ederal lows. <br /> APPLICANT'S SIGNATURE <br /> Title: OWNER Date: 04 MARCH, 2000 <br /> AUTIIORIZATION To RELEASE INFORMATION: In addition to the above, when Applicable, I, the owner, operator or agent of as of <br /> the property located Pit the above site address hereby authorlFre the release of any And All results, geotechnical data andlor <br /> environmental/site assessment Information to SAN JOAoUIN COUNTY. PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISICN as soon As <br /> It In available and At the same time It Is provided to me or my representative. <br /> Nature of Service Request. ' �!i�Wk• Service Code <br /> Assigned to E+rployee * Date / / <br /> Date Service Completed / / Further Action RegUlred: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type. Receipt R Check N. Reevd:!!By <br /> 6 Z11OL6q Com- D60/4, <br /> RFHS+ 1 / SUPV �/ / ACCT �/ / UNIT CLK� /tel <br />