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e <br /> SERVICE REQUEST <br /> (SERYIREO) Revised 5/13/93 <br /> FACILITY to NRECORD 10 A BILLINO PARtY Y / <br /> VACILltt wm Sears Roebuck & Co. <br /> fill ADbREEh " 5110 Pacific Ave. <br /> Stockton, 95207 <br /> V,—L, <br /> r CA ZIP " <br /> Sears Roebuck & Co.�:"txMEk/oPERA1DR BILLING PARTYfRmg #I <br /> / <br /> ti q, <br /> ADOR�es 2100 N. Tustin <br /> it? <br /> ;_= Orange, CA 92655 <br /> 4. STATE ZiP <br /> APN 1 Census -•--•---- BOS 01st- Location Code City Cods •°•--- <br /> CONTRACTOR and/or Jim Thorpe Oil, Inc. <br /> SERVICE REOUESTOR 1:EKL <br /> NO PARTY Y / N <br /> DBA Rich-Mart Construction PHONE Al (800 844 . 6175 <br /> t <br /> HAILING ADDRESS P.O. Box 357 FA% # (209 ) 368 . 1$51 1 <br /> Lodi <br /> el TV CA 95241-0357 ?!; <br /> STATE ZIP <br /> memo <br /> RiLLIHO ACKNMEDGEMERTi I, the undersigned owner, operator or agent of some, acknowledge that all site and/or" project specific <br /> PHS/EHO hourly charges associated with this facitlty or activity will be billed to the party Identified as.the 91LLING PARTY an <br /> Page 1 of this form. <br /> 1 also certify that i have prepared this application and that the work to be performed will be done In accordance with sit SAM <br /> JOAQUIN C%MIY ordinance Codes and Standar , State and Federal lows, <br /> tAPPLICANTIS SIGIMURE If �—• , <br /> Dates <br /> AUTHORIZATiON To RELEASE INFORMATION* In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property toceted at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> enviro mentet/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the some time it Is provided to me or my representative. <br /> Nsturt of Service Requeste Service Code # <br /> k <br /> Assigned to Employee / Date <br /> a <br /> i <br /> Date Service Completed / / Further Action Requiredn Y / N [PROGRAM ELEMENT <br /> r • <br /> Fee Amount Amount Paid Date of Payment Payment type Receipt R Check ! Recvd By <br /> RENS / / SUPV �/ / ACCT _____/ 1 UNIT CLK <br />