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• SERVICE REQUEST • <br /> _ (SLx VREO) Revised 8/23/95 <br /> IAI II IIY IDN l �✓ / RECORD ID N <br /> - - -- � INVOICE N <br /> I` FACILITY NAME L..oJ 5 A ISc ..7 � BILLING PARTY y <br /> SITE ADDRESS _-.�Zc?j-(-p•d j�/��, N `' <br /> / CITY I �c.:] CA 21P sj— t2 �--- <br /> _71-(IWNER/OPERATOR �� tL-�j•, t- f� �.�. BILLING PARiY Y / M <br /> 'Y DBA ( I I &io PHONE N1 ( ) <br /> ADDRESS ;.-d�aae�s� �jLSGOV hC v 0!::!aC \ PHONE 02 ( ) <br /> CITY �ncr > �� STATE t'n zip <br /> ArN N Land Use Application N <br /> 711 BOS Diet Location Cock <br /> CONTRACTOR end/or <br /> SERVICE REOIIES TOR Gy Lr, s s_-��1 co N -v\o ,,�5 W� � BILLING PARTY y / N <br /> DBA PHONE M1 <br /> HAII ING ADORESS FAX N <br /> CITY STATE 21P --__—_�- - <br /> R I I t.I NG A04ONLEDGEMENA I, the undersigned oNNer, operator or agent of Ram, acknowledge <br /> FIsfhourly charge, associated with this facility Of activity will be billed to the party h Ideat ntifieIt d•ofharaILLINgrojtPANtYio,'c <br /> [Inge 1 of this form. <br /> I Al';o certify that I have prepared thl pPlication and that the work to be perforated will be dote In accordance with al( SAN <br /> JDAu11N COUNTY Ordinal aCodes and S[arder State atd Federal laws, <br /> APPIICANTcS SIGNATURE <br /> 1 ,r — / <br /> - - ....e._ l�/ <br /> C.E.S. .. - _-. <br /> .0. BOX 245195 <br /> SACRAMENTO CA 95824 �Xl <br /> (916) 649-8955 <br /> PAY <br /> TOTHE APRIL 18 <br /> / SO T 19 94 11__24 <br /> �nnPR of SAN JOAQUIN ENVIRONMENTAL HEALTH 121018, <br /> FIVE HUNDRED EIGHTY FIVE AND 00/100____________ _ <br /> _--- $ 585.00 <br /> 1 NORTH SACRAMENTO OFFICE <br /> WELLS FARGO BANKC ----- DOLLAR <br /> i 1501 DEL PASO BOULEVARD.SACRAMENTO,CA 95"15 \ <br /> I Fort DON'S DISCOUNT LIQUOR - <br /> Q STOCKTON <br /> I: 1 2 1000 2t,FBI. 38 5 <br /> 0697528■ <br /> RFIIS /_ / ACCT <br /> SUP __ _ __ <br />