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i <br /> SERVICE REQUEST k �, <br /> Type of Business ar Properly FACILITY 10# SERVICE REQUEST <br /> BILLING PARTY 0 <br /> OWNER I OPERATOR <br /> WOODBRIDGE PARNTERS , INC . <br /> FACMM NAME VICTOR MEATS <br /> SflEADonss 1gg46 A�NORTH STATE HIGHWAY 99 <br /> Streer Num6ar StreK Name tYP+ Suite! <br /> Mailing Address (If Different from Site Address <br /> 639 EAST LOCKEFORD STREET <br /> CITE STATE CA ZIP 95240 <br /> LODI <br /> PHONE#1 EXT. APN# LANOUSE APPLICATION# <br /> (2091333-1116 017-090-51 <br /> PHONE#2 Err• BOS DisTR>c r -: '- LOCATION <br /> Co. : <br /> CONTRACTOR I SERVICE RECUESTOR <br /> REQUESTOR SLUNG PARTY j <br /> FORD CONSTRUCTION COMPANY , INC . <br /> BUSINESS NAME PHONE# <br /> FORD CONSTRUCTION COMPANY INC. 09) 333-1116 <br /> M1uuNG AnoREss FAX# <br /> 639 E. LOCKEFORD S'T'REET0 333-8597 <br /> C;TY LO D I STATE CA 71P 95240 <br /> BILLING ACKNOWLEI3GEMENT: I,the undersigned property or business owner,operator or authorized agent of same.acknowledge that ad srle andtar project specft <br /> Pusuc HEALTm SERvicEs ENVIRONMENTAL HEALTH DIVISION hourby charges assodated Wdh Cre pro}ect or activity will be b led to me or my business as ideaffed on the form <br /> I also certify that I have prepared this application and that the wont to be performed wi11 be done in amordance with all SAN JCAOUt.M COUM Oerrnsnce Codes,Standards.STATE and <br /> FEDERAL Saws. <br /> -��APPLICANT SIGNATURE. ] DAA; AUGUST 7 _2000 <br /> Pi;CPERrY I BUSINESS OWNER lel OPERA OR 1 NWuC R ❑ OmER Aunio zED AGENT ❑ <br /> X APFLCAMT is rX t the Bu.aa Paan.Boat Of of wthadatlon to SAP ngrrind rifts <br /> AUTHORMATION TO RELEASE INFORMATION:When appricable,I,the owner or operator of the property located at the above site address,hereby auttviaa the release of <br /> any and atl results.geotechnical data amllor environmentalfsitee assessment inbTnatlon to the SAN JOAWN COUNTY PUBLIC HEALTH$SWaS ENVIRONMWAL HEALTH ONMON as soon <br /> as it is available and at the same time it is provided W me or my representative. <br /> TYPE OF SERVICE REcuESTED: f_ 1 q r <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> AUGSAN cOUNTY <br /> - s z0oo <br /> PUBLIC HOUTH S RMCES <br /> ENVIRONMENTAL HEALTH OIVIS10N <br /> INSPECTOR'S SIGMA-MRE: CONTRACTOR'S SIGNATURE: <br /> APPROVEDOY: .nom EY>'1^Y�#: tj f OA7F: <br /> AssiGNEo To: EmpLOYEE#: 7� DATE: <br /> Date Service Completed (If already completed}: SERVICE CODE:- .6.fx P/E <br /> Fee Amount Amount Paid � 7�3 Q : Payment Date S �� <br /> eived By:Payment Type Invoice# Check >TJ Rec <br />