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SERVICE REQUEST S-- # `SERVR +) Revised 5/13 <br /> FACILITY ID # RECORD ID # ff <br /> 8 LLING PARTY Y / 11 <br /> mili 7T <br /> FACILITY NAME 2 _�� V # (7O0 <br /> SITE ADDRESS / —I D <br /> CITY . �cocCA ZIP <br /> S (� <br /> OWNER/OPERATOR �I F �H YYl S F'_ v BILLING PARTY Y n/ N <br /> DBA HFY15�V -!Jl 1 IE15; 4Y-t 4�-Q-V . PHONE #1 ( ) 7 - e 7: <br /> ADDRESS Pao—. e?� ,Dx_ 9"�,�{ ,Z Q PHONE #2e(,;2kuq)VL-, ?c43 <br /> CITY �7�OC,C-�G�) jI STATE ZIP <br /> ZIP <br /> Census <br /> � <br /> APH # Census --------- BOS Dist Location Code City Code ------ <br /> CONTRACTOR and/or Jim Thorpe Oil, Inc. <br /> SERVICE REOUESTOR BILLING PARTY <br /> DBA Rich-Mart Construction PHONE #1 (209_)368_U175 <br /> MAILING ADDRESS P.O. BOX 357 FAX # <br /> 209 ) 36$;1851 <br /> CITY Lodi, STATE CA zip 95241-0357 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EMD hourly charges associated with this facility or activity will be billed to the party identified as.the:BiLi ING PARTY on <br /> Page 1 of this form. APD 2 6 1994 <br /> 1 also certify that I have prepared his application and th t the work to be performed will bQ�AI`_lfli �T" CrIJIJI �all SAN <br /> JOAQUIN COUNTY Ordinance Codes and andards, state and eder laws. LNVIRDNMENTALHEALTH DIVISION <br /> APPLICANT'S SIGNATURE <br /> Title: (SI/`,(.(-)f./.Q/2 Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1,Kthe <br /> ' owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and alt 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 /> 03 f <br /> Nature of Service Request: '//19A� L(IC.-C Service Code <br /> Assigned to L I �iGG�S Employee # OC / �,� Date <br /> Date Service Cpleted Further Action Required: Y / N P <br /> omROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS _/_/_ SUP, ACCT UNIT/_" _ UNIT LLK <br /> 1 <br />