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SERVICE REQUEST 'J ,;R ISERm) Rim <br /> FACILITY ID # RECORD ID # BILLING PARTY Y <br /> FACILITYiowe 46 <br /> VALLEY WHOLESALE DRUG CO . , INC . # <br /> SITE ADDRESS-ADDRESS; 1401 W FREMONT STREET <br /> 'CITY STOCKTON, CA ZIP 95203 <br /> IF"A%OPERATOR.:--a I f1IIT4 SHnNFFF BILLING PARTY Y / N <br /> C.DPA--P VALLEY WHOLESALE DRUG CO . , INC . PHONE #1, (209 ) 466 - 0131 <br /> JURESs� 1Lf)T li FRFMf1NT 4TRFFT PHONE A2 ( ) <br /> CITY STOCKTON STATE CA zip 95203 <br /> APN # Census --------- BOS Dist Location Code City Code ------ <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR -� I/kn. YT l py[,oO L_. O� iv� �}./ BILLING PARTY Y / N <br /> DBA {/! LL /-� (�lL� Co �� / f?uC-F Cil C" PHONE #1 (.Z'. ,� )3G bfr'- G/ ;� J <br /> MAILING ADDRESS i/ .-7 O /��h ✓Z S? FAX # <br /> CITY O STATE ZIP �S L 7 •' J-� 7 <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 BILLING PARTY on <br /> Page 1 of this form. <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAW IN COUNTY Ordinance Codes S[ rds.Statrand Feder a <br /> C � ' <br /> $ APPLICANTIS SIGNATURE :I <br /> Title; t CEO— Da : 1 5/9/94 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, 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: (—�LOSIJ� Service Code <br /> �j <br /> Assigned to !D>�•� ///OLE%�7 Erryloyee # �'�...3� Date <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> � QC' <br /> RENS _/_/_ SUP _/_/_ ACCT _/__ UNIT CLK _/_/_ <br />