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ILITY ID N <br />RECORD 111, N <br />INVOICE M <br />FAC <br />IILLIND PARTY T / M <br />FACILITY NAME _.11Pff F1ima <br />SITE ADDRESS 2ann W T.t.tu <br />ORLING ACKNOdLEDGEMEMTt 1, the tsder,iyned ownaf, "rater or event of same, eclvowledye cher all site <br />and/or preleet sp— <br />PHS/END heurlY charges eaeoci-tAd with this facility or activity will be billed to the party identified as the II LLIND PARTY on <br />rape 1 hl, t <br />of form. <br />AM that the work to be performed Mitt be done In -CCOrdmcs with all SAN <br />I also certify fhIN that t have prepared this applicetlon <br />JOAOUTw COUNTY Ordinance Codes and Stsrderd9, State and Federal. laws, <br />APPLICANT'S SIGNATURE <br />5 erintendent <br />Title: 11F <br />NOTHORIZATION TO RELEASE INFORMATION: In addition to the Above, when eppliceble, 1, the oister, t*, Boor or e/ent of salad, of <br />the progrtV local eA at the above site address hereby Authorize the teles,- of Any And All resin b, NweeehniMl data and/or <br />envlrertnent el/site assesomant inf otmetian to SAN JDAQUIH COUNTY pU2LIC HEALTH SERVICES ENYIROINENiAI HEALTH OIVISICN of soon u <br />It Is available and At the Was tlme It is provided to me or my tepresentstive. <br />Service Code <br />-- <br />Nature of Service Re%*O" <br />Assigned to <br />Date Service Campletad <br />Date <br />Employee N <br />Further Action Requiredt Y / N pRo" ELEMENT �..�-- <br />m - ww� <br />f <br />CA ZIP ^co'su--y-'------ <br />CITY <br />7'r'iC-1' <br />IILLWO PARTY <br />N <br />OWNER/OPERATOR __ <br />Iaff erg Flaman <br />Nl (209 <br />1836 _ 3388 <br />PHONE <br />DBA — <br />2.09 <br />02 ( <br />836 .3388 <br />1 <br />PHONE <br />ADDRESS <br />STATE CA ZIPCIlY <br />�Y�Ln!L <br />�Location <br />code <br />APu M <br />_CONTRACTOR <br />end/er <br />Jim Thorpe Oil, Inc. <br />6ILLINQ PARTY <br />T O <br />SERVICE REOl1ESTOR <br />- <br />209 <br />1368 <br />Same as above <br />PxalE N1 <br />_-LUL_ <br />DaA09 <br />FAR <br />1368 . 1851_ <br />P.O. Box 357 <br />HAILING ADDRESS <br />('A 95241-0357 <br />Lodi, <br />STATE Zip <br />CITY <br />^— <br />ORLING ACKNOdLEDGEMEMTt 1, the tsder,iyned ownaf, "rater or event of same, eclvowledye cher all site <br />and/or preleet sp— <br />PHS/END heurlY charges eaeoci-tAd with this facility or activity will be billed to the party identified as the II LLIND PARTY on <br />rape 1 hl, t <br />of form. <br />AM that the work to be performed Mitt be done In -CCOrdmcs with all SAN <br />I also certify fhIN that t have prepared this applicetlon <br />JOAOUTw COUNTY Ordinance Codes and Stsrderd9, State and Federal. laws, <br />APPLICANT'S SIGNATURE <br />5 erintendent <br />Title: 11F <br />NOTHORIZATION TO RELEASE INFORMATION: In addition to the Above, when eppliceble, 1, the oister, t*, Boor or e/ent of salad, of <br />the progrtV local eA at the above site address hereby Authorize the teles,- of Any And All resin b, NweeehniMl data and/or <br />envlrertnent el/site assesomant inf otmetian to SAN JDAQUIH COUNTY pU2LIC HEALTH SERVICES ENYIROINENiAI HEALTH OIVISICN of soon u <br />It Is available and At the Was tlme It is provided to me or my tepresentstive. <br />Service Code <br />-- <br />Nature of Service Re%*O" <br />Assigned to <br />Date Service Campletad <br />Date <br />Employee N <br />Further Action Requiredt Y / N pRo" ELEMENT �..�-- <br />m - ww� <br />f <br />