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SERVICE REQUEST (SERVREQ) Revised 8/23/93 'FACILITY ID # 1 1 RECORD 10 # 1 1 INVOICE # 1 FACILITY NAME �� / L/�' cam" BILLING PARTY FACILITY/ N SITE ADDRESS „a /®® L-�G�✓TL.9�vG� - CITY T�X%��- CA ZIP_ MAILING ADDRESS P.O. Box 357 FAX # (2209 ) 368 - 1851 CITY Lodi, Ca 95241-0357 STATE ZIP BILLING ACKNOULEDGEMENT: t, the undersigned owner, operator or agent of same, acknowledge that alt site and/or project specific PIIS/END hourly charges associated with this facility or activity wilt be bitted to the party identified as the BILLING PARTY on Page t of this form. I also certify that I have prepared this application and that the work to be performed wilt be done in accordance with Olt SAN JOAQUIN COUNTY Ordinanc APPLICANT'S SIGNATURE : Title: Owner Date: .3/4/y4 AUTHORIZATION TO RELEASE INFORMATION- to addition to the above, when applicable, 1, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical date and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. Nature of Service Request: /}its ®s r2 ! Service Cock c� Assigned to Employee # 0 Date Service Completed / /, Further Action Required: Y / N Date 4-3 /-Z/_/ -i PROGRAM ELEMENT, Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By 3An,-743 OW14FR/OPERATORPART DBAGL��TIdLrt Fi�EIS PHONE #I (Zo`i ADDRESS^�� %_ ✓� PHONE 02 ( ) �T" �7 �� STATE ZIP ✓� / CITY -- APN # — Land Use Application # ir BOS Dist Location Code CONTRACTOR and/or SERVICE REQUESTOR Jim Thorpe 011, Inc. BILLING PARTY Y / M DBA Rich -Mart Construction PHONE #1 (209 ) 368 -6175 MAILING ADDRESS P.O. Box 357 FAX # (2209 ) 368 - 1851 CITY Lodi, Ca 95241-0357 STATE ZIP BILLING ACKNOULEDGEMENT: t, the undersigned owner, operator or agent of same, acknowledge that alt site and/or project specific PIIS/END hourly charges associated with this facility or activity wilt be bitted to the party identified as the BILLING PARTY on Page t of this form. I also certify that I have prepared this application and that the work to be performed wilt be done in accordance with Olt SAN JOAQUIN COUNTY Ordinanc APPLICANT'S SIGNATURE : Title: Owner Date: .3/4/y4 AUTHORIZATION TO RELEASE INFORMATION- to addition to the above, when applicable, 1, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical date and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. Nature of Service Request: /}its ®s r2 ! Service Cock c� Assigned to Employee # 0 Date Service Completed / /, Further Action Required: Y / N Date 4-3 /-Z/_/ -i PROGRAM ELEMENT, Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By 3An,-743 RENS I _/ / I SUPV I _/ / IACCT I _/ / IUNIT CLK I