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SERVICE/REQUEST/I CEN 00 61) Revised 8/23/93 <br /> FA.SILITY ID # RECORD ID # f ')F, I Y. INVOICE N <br /> �.iV li u CCCJJJ <br /> FACILITY NAME Albert Vetter Sr. BILLING PARTY Y <br /> SITE ADDRESS 1035 S. Aurora St. <br /> CITY Stockton. CA zip 95206 <br /> "ER/OPERATORAlbert Vetter BILLING PARTY 0 / N <br /> DBA <br /> PHONE #1 ( 209 462 .2939 <br /> ADDRESS P.O. Box 146 PHONE #2 ( 907 ). 6�97 •2357 <br /> i <br /> CITY Gustavas STATE AK zip 99826 <br /> �APN M rLard Use Application # <br /> ROS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR Jim Thorpe Gllt Inc. BILLING PARTY Y / <br /> DDA PHONE 91 ( 209 ) 668 -6175 <br /> MAILING ADDRESS P.O. BOX 357 FAX # ( 209_) 368 -1851 <br /> CITY Lodi, STATE Ci' zip 95241-0357 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that ell site and/or project specific <br /> DHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page I of this, form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY ordinance Cod St ar -and Federal laws. <br /> APPLICANT'S SIGNATU <br /> Date: <br /> �//< <br /> Tltle:�.. v Cha•4��e�MFy7Al_ <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of some, of <br /> the property located at the above site address hereby authorize the release of any and all 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 /> Nature of Service Request: %I/lil �C�✓� -/�Y Service Code r <br /> Assigned to kt fn T n ti_ y� I ` C+ �i Employee # ��o Date yam/ I / <br /> Date Service Cmpleted / / Further Action Required: Y� / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> SUPV _/ /_ ACCT / /_ UNIT <br /> -1_.._ <br />