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SERVICE REQUEST t!N 00 611 Revised 8128/93 <br /> FACILITY ID S RECORD ID S �i/ , �; (INVOICE / <br /> FACILITY MAIN Panella Trucking, Inc. ' ,ILLIHO PARTY •Y* / <br /> SIIE ADDRESS 5000 E. Fremont St. <br /> Stockton, CA ZIP 95215 <br /> elrY . <br /> OMER/OPERAIOR Panella `Trucking, Inc. SIlLINO PARTY / N <br /> DNA C t t l PHONE e1 t 209 1943 . 5000 <br /> 1 <br /> ADDRESS 5000 E. Fremont St. PHONE 82 t 1 <br /> City Stockton, STATE CA 2ip 95215 <br /> r APH a F�Lend Uae Applltat love R <br /> I I 809 Dlst location CaM <br /> v <br /> CONTRACTOR and/or <br /> SERVICE REa"ESTOR Jim, Thorpe Oil, Inc. MILLING PMiT Y / <br /> DSA �� I �•. Il f 1 PHONE 81 ( 209 1368 6175 <br /> NAILING ADDRESS P.O. BOX 357 FAX IT t 209 1"168 ' 1851 <br /> City Lodi, STATE CP, zip 95241-0H& <br /> 911[1140 ACKNUULEDGEHENTt I, the udersioned owner, operator or agent of some, acknowledge that j2pW&0 pro)ect specific <br /> pHS/Elio hourly charges associated with this facility or activity will be billed to the party Iooreft.rev\k09ILLINO PARTY oD <br /> Page 1 of this form. ��,�{�p[R� 41990 <br /> 1 alto certify that I have prepared this application end that the work to be performed will be dd�iii'1`n eeeordenee with ell SAN <br /> JOAOUIN COUNTY ordinance Codes tender —,-"ate ederal laws. puH LTF:ScRwlcFS <br /> �Tn�riEAL'�QNlsloN <br /> �uatE� <br /> APPLICANT'S SIGNATURE t <br /> Contractor Dotal 3/17/98 3T... <br /> title! <br /> AU1HVRIZAr1DN 10 RELEASE lNrtRIMAt IONt. In addltlon to the obove, when applicable, 1, the owner, operator or agent of Boom,of <br /> the property located at the above site address hereby euthorlra the release of any and all results, gsotechnical'date std/or-` <br /> em•irormental/olte assessment Information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL NEALIN DIVISION If soon n <br /> It Is available end at the some time It Is provided to me or my representative. <br /> (A ro�^/� ' <br /> Nature of Servlet Reu�testt Service Cods <br /> Asolgtxd to ! to I- Employee / l u-3 Date <br /> Date Service Ccuplsted / / Further Action Required: T / N PRDGRAM ELEMENT 7!) 10 <br /> Ica Amount Amount Paid Date of Payment Payment type Receipt / Check a Reevd By, <br /> ACCT __/_/_ _ UNIT CLR <br />