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SERVICE REQUEST (EN 00 61) Wised 8/23/93 <br /> FACILITY IDA RECORD IDN �L - INVOICE A i �IJ <br /> Vogue CleanersBILLING PARTY y / <br /> FACILITY NAME <br /> SIZE ADDRESS 2315 N. California St. <br /> city <br /> Stockton, CA =1,95204 <br /> ONNER/ODERATOR Norman Higgins BILLING PARTY <br /> DBA PHONE 41 ( 209 ) 759—.'3400 . . <br /> ADDRESS <br /> P.O. Box 369 PHONE N2 <br /> I <br /> CITY Clements, STATE CA ZIP 95227 <br /> p ppN NpLerd Use Application N ROS Diet Locetlon Code <br /> CONTRACTOR end/or I <br /> SERVICE REOUESTOR Jim Thorpe Oil, InC• BILLING PARTY Y / <br /> DBA PHONE 01 ( 2.09 I -16R 6175 j <br /> HAILING ADDRESS P.O. Box 357 FAX N (n4 )_,368._- 18-11 <br /> CITY Lodi, STATE CA zip 95241-0357 <br /> BILLING ACKNONLEDGEMENt1 1, the undersigned owner, operator or agent of am*, acknowledge that all site and/or project specific <br /> FHS/EHD hourly charges associated with this facility or activity will be billed to the party Identif led as the BILLING PARTY on <br /> Page 1 of this, form. <br /> I Also certify that I have prepared this application and that the work to be performed will be done In,*Wdence with ell SAN <br /> JOAIN COUNTY ordinance Code andards a Federal laws. �F r/ '�N j` <br /> W <br /> C�I v <br /> MA <br /> APPLICANTtll SIGNATURE qN 9p <br /> Contractor IT Date: 5/16/96 EIV PILI �UaO�i <br /> Title- /� QL'wQQQ������,��'vri: <br /> 116N'q, / �N.S f. <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operst '*At QqSssene, of <br /> the property located at the above site address hereby authorize the release of any end ell results, peotechnlea �jbtR"AgVor <br /> environmental/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ee soon ee <br /> It is available and at the same time It is provided to me or m/ representative. <br /> Nature of Service Request- Service Code p <br /> j� 9. L Date / <br /> Assigned to I i Lam.-l,LtTL�— L,.x-A�-Z-� Eaployee N V _i �-�Q <br /> Date Service Colleted _I—/— Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By <br /> RENS /_ SUPV _/_/_ ACCT _/ /_ UNIT r. _/_f_ <br />