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SERVICE REa11 - (EN 00 6I1 <br /> E5T RWI11ed D/2S/0'I 1 <br /> INVOICE A <br /> IACILItY IDN RECORD IDN . I <br /> PAI NAME <br /> Star Building Systems BILLING PARTY / N �I <br /> RITE ADDRESS 12101 E. Brandt Rd. <br /> city Lockeford, CA 95237 CA zlv i <br /> URIER/aPERAtoR Same as above BILLING PARTY Y <br /> PHONE NI l_209 727.'a50-4 - <br /> ORA <br /> ADDRESS PHONE 02 ( )- .- •I! <br /> CITY STATE ZIP I <br /> APN S ppp Land Uoe Appticatlon A i�1 <br /> 1 SK Dist Lecetldn Code <br /> I <br /> toNTRACTDA &I <br /> (SERVICE REQUESTOR Jim Thorpe oil, Inc. enuwo PARTY Y / <br /> PHONE AI -O 6175. <br /> DBA <br /> NAILING ADDRESS P.O. Box 357 _ FAN A ( 2no t_368..• tR�T . - <br /> Ctly Lodi, STATE CA zip 95241-0357 <br /> 81111.140 ACKNOIILEDaEMENTt 1, the undersigned owner, Operator or agent of NAmm, acknowledge that ell site end/or prOJeet speelfle <br /> QHS/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. �I <br /> I Also certify that 1 have prepared this application and that the work to be performed will be done In accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Code tandards Federal laws. <br /> �I <br /> APPLICANT'S SIGNATURE I <br /> Tltta, Contractor Dates <br /> AUTHORIZATION TO RELEASE INFORMATIONI In addition to the above, when n1ticable, 1, the owner, operator or agent of 1101", of <br /> the property located at the above site address hereby authorize the release of any and sit results, geotechnical data and/or <br /> Nwltormental/Alto aseesement Information to SAN JOAQUIN M NTY PUBLIC IEA011 SERVICES ENVIROHMENtAL HEALTH DIVISION as soon N <br /> It Is available and et the same time It Is provided to me or my representative. <br /> i <br /> Neture of Retvlee 000I Service Cale <br /> Asslgned to Employee A Date <br /> Data Service Completed _/ / Further Action Requlredl Y / N PROGRAM ELEMENT 4 1 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt A Check A Recvd By i <br /> S <br /> i <br /> : <br /> , <br /> RENS _/_/_ SUry _/_/_ ACCTUNIf r� ,. /_J__ !� <br /> • 1 <br /> i <br />