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<br /> r F SERVICE REQUEST (SERVREQ) Reylaed 8/23/937
<br /> 1-771
<br /> RECORD INVOICE l
<br /> J & L ..Market,
<br /> MANE _ DiLLINQ PARTT
<br /> oaESS 8115''S9u'th El Dorado Street 7.
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<br /> F ren 'Cam[ cn ZIP 95231
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<br /> AIOR BILGING PARTY YERA
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<br /> nnA J &•L Market ' c ,> 97 t
<br /> PHONE 209 '982 -08 4
<br /> nAEss .8115 South [ 1[lo'r di' S ti eat . , pi,tiFie rz t .209 r°982
<br /> �yr •y -- —_— i _ G 5). - { t. 71c a Mi x✓�1 F.- q2;rS ,7
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<br /> circ French"Camp sr`ArE Ca
<br /> -zip 95231 ,
<br /> Land Use A[-IAIcation
<br /> BOS Dist Locat(on Coc{e,
<br /> or, .,
<br /> «>fsroa F11 IV orltra t to Tim Gl pson BILLING PARTY Y�<i, yyrs,• .�•
<br /> BA � , PHONE �T� ., a A, .�x, �, ,};,t^.t h•F:77k �r �
<br /> (2Qg ) `461 f 337'�ti;�4y
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<br /> Dauss3f�Teept iu lit =' FAX
<br /> r77
<br /> CIli", STATE ` 21P =94205
<br /> CXNMEDGEMENT: I,':the trxJerslgned owner," operator or age-fit, of same, aacknowlecige that all site and/or pro ject'speciflc' ',
<br /> airly charges'associated wIth.thls`fscility or 'activity will be bllleJ to the party Identified •s''the'.BILLING PARTY on
<br /> thie`torm. �,..
<br /> rtlfy that 1 have prepared this aFpllcation end that the work to be performed will be done in accordance with att SAN
<br /> IT Ordinance Codes and Standards, 'State.and Federal laws J U7 - d
<br /> S�SI
<br /> tOHATURE �» 4l�� •..r �; c•{
<br /> S .. —
<br /> Date.
<br /> TION TO RELEASE INFORMATION: In addition to the above; when applicable, 1, the owrxr, operator or agent of same,,"of
<br /> yty located at the above a I t e address hereby authorize the release of any and all results, geotechnlcali'date.and/or
<br /> tai/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as
<br /> lllabit and at the same time It le provided to me or my representative.
<br /> f Service Request: Serv(ce Codec@ � `
<br /> to t a ''rkrtEtfr�loyee 'i .S° ' � +` � ., ,r 1' Date'
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<br /> t"`JJ Amount
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