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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID M <br /> RECORD ID N I r � INVOICE N <br /> i <br /> The Fannie Mae TY Y / (N`Foundation BILLING PAR <br /> FACILITY NAME <br /> SITE ADDRESS 25433 Eunice Rd. <br /> e1Tr , Aca)moo, CA zip 95220 <br /> The Fannie Mae Foundation BILLING PARTY y / N <br /> OWNER/OPERATOR <br /> 209 477-7204 <br /> PHONE 01 ( > <br /> DBA <br /> 7743 N. West Lane , Suite C 1 PHONE N2 ( ) <br /> ADDRESS <br /> Stockton. STATE CA ZIP 95210 <br /> CITY—APN N Lard Use Application N _ Location Code <br /> BOS Dls[ <br /> CONTRACTOR and/or - BILLING PARTY Y / N <br /> SERVICE REQUEST OR 'Iim Thorpe Oil. Inc. <br /> PHONE Ni (209 )_L68 Ft175 <br /> DBA <br /> 209 368 1851 <br /> MAILING ADDRESS <br /> P.O. Box 357 FAX N c ) <br /> Lodi ('A ZIP 95240 <br /> � STATE CITY <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that Ott site and/or project specific <br /> PIIS/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 also certify that I have proper his application and et the work to be performed will be done in accordance with sit SAN <br /> JOAQUIN COUNTY Ordinance Cade and tandard Sto derat lows. v <br /> APPLICANT'S SIGNATURE <br /> Contractor 7/8/95 <br /> Date: <br /> Title: <br /> AUTHORIZATION TO RELEASE INFORMATION:. in addition to the above, when applicable, 1, the owner, operator or agent of sane, of <br /> the property located at the above site address hereby outhori Te the release of any and all results, geotechnical date and/or <br /> environmental/site assessment Infonrotion 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 ae or s0' representative. <br /> 1 Service Cada � <br /> Nature of Service Request: A- �,IZ r� �.Mb <br /> Date <br /> Assigned <br /> Assigned to I F ' Enployee N >> �`L' <br /> / Further Action Required: Y / N PROGRAM ELEMENT <br /> Date Service Conpleted <br /> Recei t N Check N Recvd By <br /> Fee Amount Amount Paid Date of Payment Payment Type P . <br /> i <br /> _/_/— <br />