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• SERVICE REQUEST •� (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # <br /> FACILITY NAME DDRW— Sharpe Facility BILLING PARTY Y / N <br /> SITE ADDRESS 700 E. Roth Rd. / P.O. Box 960001 , Building S-108 <br /> CITY Lathrop, , CA CA zIP95330 <br /> OWNER/OPERATOR DDRW- Sharpe Facility BILLING PARTY Y / <br /> DBA PHONE #1 (209 ) 982 . 2427 <br /> ADDRESS 700 E. Roth Rd. / P.O. Box 960001 BuildingS-. 08 <br /> 1 ao9 832 _ 1 4 <br /> PHONE #2 ( , ) 9 9 <br /> CITY Stockton, STATECA zip 95296-0800 <br /> FAPN # � Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR Jim Thorpe Oil, Inc. BILLING PARTY / N <br /> DBA PHONE #1 (209 > 462 - 4581 <br /> MAILING ADDRESS P.O. Box 357 FAX (209 368 - 1851 <br /> CITY Lodi, STATE CA zip 95241-0357 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/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 /> 1 also certify that I have prepared this application a at the work to be performed will be done in ac�Qr,�l@pgs.11ith�ll SAN <br /> JOAQUIN COUNTY Ordinance Code nd tandards F deral laws. 7'A T M C ry <br /> APPLICANT'S SIGNATURE RECEIVEn <br /> Title: Contractor Date: 7/6/95 SAN JOgCruuv CuuwPdatic 11' <br /> HEALTH SERVICES <br /> tNVIRONMENTA NNE�1 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or eg�rit by Ts�n@JVbBIO N <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data 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: (' 6 ervice Code <br /> Assigned to \S ✓lG`ir1y, Employee # Date C1 <br /> Date Service Completed Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> -3 a - (o ,� <br /> RENS _/ / SUPV / / ACCT _/ / UNIT CLK _/ / <br />