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SERVICE REQUEST (SERVII R#Naed 5/13/93 FACILITY ID # RECORD ID # / ID BILLING PARTY FACILITY NAME polar Macer Inc. 111//J SITE ADDRESS im9 w F.mm�ar b CITY SM.-u,,.. A ZIP Q52n9 BILLING PARTY OWNERIOPERATOR R.Md M'ma,A,.A DBA Polar Water Inc. PHONE#1(20914ee-0788 ADDRESS CITY Sfmkt n. STATE CA ZIP 95203 APH# Census ------------- BOS Dist Location Code CRy Code ----- CONTRACTOR and/or SERVICE REOUESTOR Jim Thorpe Oil, Inc. BILLING PARTY DBA Rich-Mart Construction PHONE#1 ( 800 )-$g_- 6175 MAILING ADDRESS P.O. Box 357 FAX#( 209 1368 - 1851 CITY Lodi, STATE CA aP 95241-0357 BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on Page 1 of this form. I also certify that I have prepared this application and that the work to be performed will be done In accordance with all SAN JOAQUIN COUNTY Ordinance Codes d Standards, State and Federal laws. APPLICANT'S SIGNATURE:X Tltie: t'11' v er Date: / `d.,__7-9Y'I AUTHORIZATION TO RELEASE INFORMATION: In addition to the above,when applicable, 1, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as It Is available and at the same time It Is provided to me or my representative. Nature of SeMce Request: SeMce Code Assigned to Employee #_ T ( Date ( / Date SeMce Completed _/_/_ Further Action Required: Y / N PROGRAM ELEMENTQQ Fee Amount Amount Pe Id Date or Payment Payment Type Receipt# Check U Recta By 4 FLrA REHS _/_/ SUPV ACCT /�V/ ✓rt UNIT CLK a TD��