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.�,,. SERVICE REQUEST _ (SERVREQ) R ised 5/13/93 <br /> Pix` FACILITY IDM RECORD ID # `R - <br /> i <br /> du <br /> ;A FACILITY NAME V�dV7pE I ll <br /> SITE ADDRESS 9SU$ �'t d {;< <br /> 4Y <br /> clrY F✓Cj nC(/l li^IVl CA zip <br /> �- Xq <br /> �- OWNER/OPERATOR MlDol-w BILLING PARTY Y / N <br /> DBA PHONE O f <br /> ADDRESS —(50� � • Q1//I etvi ;•4?eta ,A q PHONE 92 ( ) <br /> CITY �N'ef�t�Vl l..0 l'l�ft� STATE VT ZIP <br /> e' <br /> APN # Census ••••••... I BOS Dist Location Code City Code •••••- <br /> l ; <br /> i CONTRACTOR and/or <br /> �- SERVICE RE"STOR `EMw BILLING PARTY Y / <br /> f ,(. DBA r�1, PHONE #1 ( U) ) ) SZ (6S3, <br /> NAILING ADDRESS lZI�I � 1 lvt ' FAX # 1 ) S'LtI - OSO3 <br /> M CITY (VladeS4-o STATE 64 ZIP 4 79_1 <br /> E l:. <br /> �.. BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EHD hourly charges associated With this facility or activity will be billed to the party identff�Yas the ILLING PARTY on <br /> .Page 1 of this form. - ME <br /> RECEIVED <br /> 1 also certify that 1 have prepared this application and that the work to be performed Will bed a i:Wce.,with all SAN <br /> JOAQUIN COUNTY Ordinance Colles and Standards, State and Federal laws. ���� � <br /> SAN JOA'I' <br /> APPLICANT'S SIGNATURE YflL C' PUBLIC' r� <br /> Title: ( W� u rk5rtW1 ,GtitNlCyG� Date: <br /> 1 , <br /> - AUTHORIZATION TO RELEASE INFORMATION: In addition to the.ab0ya-whl..-A^�•1 - __��_- agent of same, of <br /> ! the property toearad -_-T-3C-�- ical data and/or <br /> 1178 <br /> --- <br /> i <br /> i„ enviroJr,- DIVISION as soon as <br /> It Is , <br /> 1 SEMCO WORKING ACCOUNT II19 (ar / <br /> RICFIARD C. HAMILTON —� g0-tog/7211 t <br /> Natul 1217 S. 7TH ST. Pil. 209-524-9653 ) <br /> MODFSTO, CA 95351 <br /> Assi9 (� $a3y, <br /> 1 Par To !/ . <br /> The Order Of '_Dollars <br /> 4 Date 11 e 1 2 q:3 . 0,�) <br /> t <br /> 1 l <br /> r ) <br /> ee . t UNION SAFE DEPOSIT BANK Reevd By <br /> 4600 BROADWAY.SALIDA,CA 95368 {o //^• 11 <br /> L 1 For <br /> Ec, <br /> r ' - - - - /- - -- --- - ---J <br /> r -___.r- - _- I ACCT I �_/ UNIT CLK <br /> �+Ir <br />