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SERVICE REQUEST (SERVREQy) ROVISeQ °ry173 <br />FACILITY 10 N <br />RECORD 10 N <br />FACILITY NAME Insf VIA.,a.LyY.y—S.Qlup LIMa,. ,Y <br />SITE ADDRESS <br />CITY _ T v -. ._ CA ZIP 95'i76 V ��•� _ <br />.TPffPran Fl t C h t iHo <br />BILLIND PARTY � / N <br />OWNER/OPERATOR <br />L., rru <br />PHONE N1 1209 ) 836 _ 3388 <br />DSA __ <br />PHONE Nt 1209 ) 836 .3388 <br />ADDRESS <br />CITY _ Tracy STATE CA ZIP <br />APN M Census ........ BOS Dist Locstlon Code <br />City Cee* ••^" <br />CONTRACTOR ardlor Jim Thorpe Oil, Inc. BILLIN4 PARTY Y / <br />SERVICE REQUESTOR <br />Same as above PHONE N1 1209 )368 .6175 _ <br />DBA _ <br />P.O. Box 357 <br />FAX 0 t209 )368 . 1851 <br />NAILING ADDRESS <br />Lodi, STATE(A tip 95241-0357 <br />CITY -- <br />BILLING ACKNWLEDGENENt: 1, the Utder%I$ned owne' operator or spent of same, ackrtowledpe th'tderaiCifiEd a �rcproject <br />LllN tPAR YT 34)"171c <br />BILLING <br />PHS/END hourly charges associated with this facility or activity will be billed to the party <br />Gape 1 0f this form. <br />and that the work to M performed wlll M an <br />done in Accordance with ell SAN <br />I else certify that I have prepared this applicetfon <br />JOAOUIN COUNTY Ordinonee Codes and Standards, Sr and Federal lawn. <br />APPLICANT'S SIGNATURE t <br />Title: <br />Superintendent __�,,,�._._ Dat°° I)o hnr 4 1 qq4 <br />same, of <br />AUTHORIZATION TO RELEASE INFORMATION: In Addition to the Above, when applicable, I, the other, operates or scant of <br />the property located at the above site address WOW authorize the releeae of arty and all results, goo ch date °ndlor <br />therrateentel/site assessment infornetien to SAN JOAQUIN COUNTY PUBLIC BEALTN SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />et%yiit is available and at the same time it 1a provided t0 me or my repretuntative. <br />L <br />Service Request!oice Completed <br />res Amount Amount Peid <br />W <br />M <br />Eeployee N ) I � Z <br />Further Action Required' Y / N <br />Date of P:::t PAYWT Type Receipt k <br />IACCT <br />service Cot* <br />Date /-_ / <br />PROGW ELEMENT <br />Check N I ROM M <br />UNIT CLX I /----J <br />