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� •1 <br /> 1 <br /> SERVICE REQUEST + (EN Do 61) Revised 6/23/93 <br /> RECORD 10 N n INVOICB / <br /> [FACILITY IDN � <br /> Sun West Liquors ri1LLt110 vMtY Y' / Q <br /> FACILITY NAME <br /> S1TE ADDRESS 2449 W. Kettleman Ln- <br /> Lodi,, <br /> Lodi, CA ZIP 95242 <br /> J81Tles Anagnos BILLING PARTY / N <br /> OwHER/OPERAI011 <br /> PHONE St ( 209 ) 333 1036 <br /> DBA <br /> 847 N Cluff Ave. PHONE N2 ( 209 ) 3G6 .1150 <br /> ADORERS ' <br /> Lodi, CA 95210 <br /> CITY STATE ZIP <br /> APN S E�Lend Vee Ahpl lest tan N <br /> IB09 Olat Loeatlon Coda <br /> CONTRACTOR nrd/or jim r1borpe oil, Inc. BILLING PARTY Y / <br /> SERVICE REo1IEStOR <br /> PHONE NI ( 209 ) 368 - 6175 <br /> DBA <br /> MAILING ADDRESS P.O. Box 357 FAX N ( 209 ) 368 - 1851 <br /> CITY Lodi STATE CA ZIP 95241-0357 <br /> � <br /> BIIt INO ACKMOVI-EDGEMENtt 1, the undersigned owner, operator or agent of some, acknowledge that sit alto end/or project specific <br /> PHS/FHO hourly charges associated with this facility or activity well be billed to the party Identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> -.� a(ioks <br /> 1 also certify that I haus prepared this application and that the work to be performed will be done In 'With sit SAN <br /> y <br /> JOAOUIN COUNTY Ordinance Code! ands, State ed /e Fal Tows. v <br /> S '� L4t7D <br /> APPLICANT'S 419NAl URE r 9,e^T'!F� <br /> CTy <br /> ntlr. Contractor Datet 5/7/98 <br /> ALFIRCRIZATION To RELEASE INfORMATIONI, to addition to the above, when applicable, I, the owner, operator or spent of sane,.of <br /> the property located at the above site address hereby outhorlre the release of any and all results, geotechnieat'date and/or. <br /> mrvlro ntal/sits assessment Information to SAN JDAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION a Sao" as <br /> It is available and at the Bene time It Is provided to me or m/ representatlw. 1: ` <br /> �7 �.. Q �}J <br /> Nature of service Reclueett �� S �-Y,D �--� / Service code <br /> �p <br /> Alslgled to L\ a iC "� t �—� Employee 0 OLD CJ U Date <br /> Data Service Catpiated _1_/_ Further Action Required: T / it PROGRAM ELEMENT � i17� • <br /> Pat Amount . Amount Paid gets of Payment Payment Type Receipt I Cheek N Raevd ' By.., <br /> +Fur N i / 7 SWV —r UNIT CLN <br />