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SERVICE REGUE Si (SERVREG) Revised 5/13/43 <br /> FACILITY 10 S T RECORD ID S 7%7,7 BILLING PARTY Y / N <br /> VAmt1FIT <br /> / <br /> elft ADORER W/5 W CA e R l,VAf <br /> lf1t�_ S-uC4�4-un CA ZIP iS91 <br /> �aL <br /> DIMEt/OPERAfoR �/V W �, Lp 1 _ BILLING PARTY / N <br /> ttv'" Gua /41f1t STATE C Zip _ �2y <br /> APN SI <br /> Census •••--•-•- SOS Dist Locatlm Coda City Cale ••---- <br /> CONTRACTOR and/or _ <br /> SERVICE RE"STOR Jim Thorpe Oil, Inc. BILLING PARTY <br /> DBA Rich-Mart Construction 800 84 <br /> PHONE 01 ( ) 4 6175 <br /> NAIL P.O. Box 357 INO ADDRESS FAX 0 (209 5 368 . 1851 i <br /> Lodi, <br /> clly STATE CA xlv 95241-0357 <br /> i <br /> BItt INO ACkNOJLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/END 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 8180 Certify that I have prepared this application and that the work to be performed will be doe In accordance kith all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal take, <br /> APPLICANfit SIGNATURE I"/ <br /> ♦ h Detail T/(f(4 y <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and sit 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 /> 11 � I <br /> Nature of Service Requatt,}(1W Ice Code i:214 ' <br /> Asslgned to � C 1 <br /> Employee / __ Data <br /> Date Servle! Completed Further Action Required: Y / N — PROGRAM ELEMENT ' <br /> Fee Amount Amount Paid Date of Payment Payment Type Recelpt S Check / Recvd By <br /> Z � <br /> RENS _/_/_ Spy _/_/_ ACCT _/ IINIT CLK _/_/ <br />