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.a 1f74�n'.,1r i.F;lilll.• <br /> , <br /> w eENvlt! NEo1E1T CIN 00 &11 Nov low WWII <br /> fAtllltT IDI Alcaao ID 1 J / /C��j INVOICI I <br /> ►ACILIIy MAMII Van De. Pol Enterprises �IllINO ►Mly �T' / <br /> fill ADDNEII 3147 S: E1 Dorado St . <br /> city <br /> Stockton, tA LIP 95206 <br /> ' bIMEA/ORlRAtDlI Van De Pol Enterprises 01111110 ►Altty y / N <br /> rNMI NI <�Q1._1_1l.Cz. ;C) . . <br /> DNA <br /> ADDNlff P.O. Box 1107 PNM 02 t ) <br /> euy •.--- <br /> Stockton ; NIAI! CA !Ir 95201 <br /> APO NLend Use Appel leas lon s <br /> 10! 01st leeatlslt Oads <br /> toMINACtoll end/er Ji r-. Thorpe Oil , Inc. 011LING PAW T / <br /> fERvice WINII( l <br /> DNA piston 01 t 209 1 3r6,$ 6175 ' <br /> NAIL INtl ADORElf P.O. Box 357 IM 1 ( 209 ) Ia.LL 1851 <br /> "q <br /> city Lodi, NtAI! CA ZIP 95241-0357 <br /> NIILIND ACtNDULEDDEHENtr 1, the undersigned owner, operstor or event of some, ocknowladee that ell site no/orproject specific <br /> Pill/ton hourly eherses associated filth this facility or activity will be billed to the party Identllieo a the ULLINO PARTY on <br /> reg* I of this form. <br /> I also certify that I have prepared this application and the the work to be performed w1eordsme with alt sed <br /> JCl1vUIN ttAINtT ordlrmrxs coda I rde at 1 laws. RFCFIV,F s . <br /> 'a •,v <br /> ArrLICABi'f fICHAtURE r AUG <br /> Contractorenter 8/1919 ANaoA qtr' <br /> ittlet ---t ,�aHe"CALTH <br /> NMENTAI ia� ERVICES •- <br /> AllIi10N1Utld1 to REllAS! IN►DRHAtldlt, In addap <br /> ltlm to the above, when plicable, .1,. the newer, op F�l4Wl�o ayen! of ums,�ef; <br /> the property located of the above site address hereby suthorlra the relesse of any end all results, petaehnleal�date rd/or:<� <br /> errvlrM wntel/site a*eteamnt Information to CAM JOAaUIN M MIT PUvtIC HEALTH 8E11YIC11 JUVIN00IMMIAL NEALtN 01y1sioN as soon as <br /> It to available and at the same time It Is provided to se or sry representstive. <br /> Neltme e4 9erv/les Aequeetl Iervlel CedO•- •� <br /> Asslpned to + �(� 1 Ci Cf 5 Employee 0 nCi t� � DNta <br /> note Servlcs tarrleted —/ / further Actlm NeWIrediCY / N rRDDRAM RIMINt ., ,b' J• <br /> fee AmoteI Amount raid Date of Payment rsyment Iype Recelpt I Check / Nsavd ' my.. <br /> ' r,; / /" ,� sure / Acct / / UNIT CLK _/—��-- <br />