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SERVICE REQUEST (SEW <br /> EQ) Revised 5/13/93 <br /> -) <br /> FACILITY 1D # RECORD�]Dl# BILLIN P RTY <br /> CATHERINE R . BEVANDA , CATHERINE A. BEVANDA ` 4iY.�".'r <br /> FACILITY NAME ' SE M . BEVANDA DBA M . J . BEVANDA PRO 17 <br /> SITE ADDRESS 221 — 225 MINER AVENUE � ,! <br /> Y w <br /> CITY STOCKTON CA zIP 95202 <br /> CWNER/OPERATOR PETER F . PERSIC BILLING PARTY y , / N <br /> DBA 7 M . J . BEVANDA PROPERTIES PHONE #1 (-24-3--)-&7Z7-- 5246 <br /> ADDRESS P.0, Box 439 PHONE #2 ( 2 1 3} 877 - 5247 <br /> CITY NORTH HOLLYWOOD STATE CA ZIP 91603 <br /> APN # 1 39-- 140-04 Census --------- BOS Dist Location Code City Code - <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR FALCON ENERGY BILLING PARTY Y f <br /> 0 B PHONE #1 ( 209 q63 - _ <br /> MAILING ADDRESS r ,O, Box 125 FAX # (-20q ?�6" <br /> CITY STOCKTON STATE C ZIP 25201-1257 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/ERD hourly charges associated with this facility or activity will be bitted to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes a S ndards, ate d ederal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: _ OPERATOR_ 0C1T BER 19 1 993 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> envirormentat/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. I <br /> Nature of Service Request: ;' ,lc(L Service Code <br /> Assigned to Employee # Date <br /> Date Service Completed —/—/ Further Action Required: Y / N PROGRAM ELEMENT �3 6y <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> [REHS / / SUPV v/ / ACCT �/ / UNIT CLK �/ f <br />