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SERVICE REQUEST <br />(EN Do 61) Revlesd 6/23/93 <br />FACILITY NAME <br />Ralph's Market <br />SITE ADDRESS __ 2122 S. Airport Way <br />Stockton, CA tip 95206 <br />IAAemPERATOR Ralph Lee White <br />DRA <br />6I LUNG OAR1Y '/ �) <br />PHONE Ri (20.9 )t.rL .•,$��� <br />ADDRESS 2230 S Airport Way PHONE NZ 1 ),..�_• <br />clTr Stockton, STATE CA ZIP 95206 <br />APN 0 p Land Use Application M <br />I ROS Dist Location Code <br />I <br />CONTRACTOR and/or <br />SERVICE REDUESTOR Jim Thorpe Oil, -Inc. FRILLING <br />PARTY <br />DBA II 6` ' ` 1 ! PHONE 01 1 %n4 )x6,9 L175 - - <br />NAILING ADDRESS P.O. •BOX 357 FAN e 1 209 )�f,8_• TR�t _ <br />CITY Lodi, STATE CA ZIP 95241-0357 <br />RILLING ACRNOMEDOENENtt 1, the undersigned owner, operator or agent of same, acknowledge that ell site and/or project specific <br />OHS/END hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY an <br />Page 1 of this, form. I <br />ppPpA�Y+A�#�E���NT <br />I also certify that I have prepared this application end that the work to be performed will be done In seeordliR!tMl i6m <br />JOAOUIN COUNTY Ordinance Codea Stgdards, Sir.. laws. JUL 2 S 9 <br />97 <br />APPLICANT'S SIGNATURE !rA <br />JOEALTH COUNTY <br />�+ b PUBLIC HEALTH SERVICES <br />Title: Contractor Date: ��� � 7 ENVIROj.111-HEWH 01VISIc <br />4' <br />AUTHORIZATION TO RELEASE INFORMATION! In addition to the above, when applicable, I, the owner, operator or meant of ease, of <br />the property located at the above aIle address hereby authorize the release of Any and ell results, geotechnical date aid/or <br />em)to"ntal/alta asaesAment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ma soon N <br />It la evellable and at the Ammo time it Is provided to me or my representative. <br />Nature of Service Requ/� <br />estl .3 —7 a !n�� 0—& & <br />Assigned to iF r T- CL 13,N„ !� S Eaptoyee / o1�4 <br />bete Service Completed _/ / Further Action Required: Y / N <br />Service Code <br />onto / � 9 /T. I <br />PROGRAM ELEMENT <br />Fee Am unt <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt 0 <br />Check R <br />7 02- - 0 <br />Z -z Z - <br />2-5-L <br />Recvd By <br />SIAV I ACCT I I I/ L7/ �(� / I UNIT r, / <br />R <br />