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SERVICE REQUEST (SERVREO) Revised 8/27/93 <br /> I <br /> ACILITY ID R :CORD ID 0 <br /> �r µµ <br /> FACILITY NAME Lloyd GWRS: A ING PANT` 0 T � / N <br /> SITE ADDRESS 3 I <br /> CITY LC) d1 CA IIP � � �Iti • # <br /> M-11FR/OPERATOR � U�q (, C-7 (A all BILLING PARTY / N <br /> DBAPHONE 01 (aa).. - Qq <br /> ADDRESS 7 �� {J ( r �I1 woo C� rive, PHONE 02 (DO )_JU2) - v0�d <br /> CITY Lo I STATE CA ��jj ZIP `'J 5 Py- <br /> I—MN R pLand Use Application I - <br /> II 805 Diet Locnt ion Code <br /> rn4TRACTOR and/or <br /> SFPVIOF RFOIIESTOR Jim Thorpe Oil Inc BILLING PARTY <br /> DBA Rich-Mart Construction PHONE #1 ung)36L3-L-17F <br /> MAILI4O ADDRESS P.O. Box 357 FAX AT (2no)-A&q- -j$51 <br /> CITY Lodi, STATE CA - IIP gS74n <br /> i <br /> AIIt ING ACKNOWLEDGEMENT: 1, the undersigned miner, operator or agent of same, acknowledge that ell %Its end/or project specific <br /> Put/FIID hourly charge" associated with this facility or activity will be billed to the Party Identified so the BILLING PARTY.on <br /> Pnge I of this form. <br /> I Ono certify that I have prepared this a cation anti that the work to be performed will be done In accordance with all SAN <br /> JOAOUIN COUNTY Ordlnanc Codes and t rds, State and Federal lows. <br /> APPLICANT'S SIGNATURE <br /> Title: <br /> Title: �(..(//�/ Dater <br /> AUTHORIZATION 10 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 ell results, geotechnical date and/or <br /> w.virormentsl/site assessment Information to SAN JDAOUIR COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as Soon as <br /> It in nvnll"ble and at the same time it is provided to me or my representative. <br /> Nature of Service Request. I_1OScfkc �C� }�(,, I�(n Service Code <br /> Assigned to L� I Employee 1 U(V l'IY Date _f / <br /> DAte Servlce Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt R Check # Recvd By <br /> SUPV I _/ / Arr.T UNIT CLK <br /> J <br />