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<br /> a SERVICE REQUEST (SERVREQ) Revis71
<br /> ed B%23J93"^ '
<br /> TTS IDI RECORD Ib k ''t 41j- r INVOICE N t nJ p[.\r r�� � '
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<br /> 'J & L .Market ' —
<br /> Y NAHE 9ILLIND PA QTY ` Y / IN
<br /> DRESS 8115 So ith ElDor ado Street
<br /> �CI1T 'F.rerich 'Camp cb ziP 95231
<br /> '.James Fjsk
<br /> AICR BILLING PARTY Y
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<br /> J & L Market 209.; }982 _ 089
<br /> DBA -47
<br /> PHONE Mt ( ) t
<br /> 209 ' 982 7,t'c'&' rx Tn
<br /> DaEss ,,81.15 Snut:h ( 1(�I�'radc� Street `', _ PU/�;e az ( : � . + .0897,
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<br /> y cirY .French Camp STATE Ca zIP •95231
<br /> Land Use All-licnt Ion _.
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<br /> BOS Diet Location Co(
<br /> a11SIOR FIT .e IV tractors - A-Ltn Tim Gipson BILLING PARTY
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<br /> DBA f ?' :. 1 ' PHONE r11 (�2-) 1_f 337 -'� l
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<br /> �73fi FAX 0 c�9
<br /> CITY, STATE _ C ZIP _c��C1r3
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<br /> LtWOVLEDGEHENT: I the undersigned ower operator or agent of saar, aacknowtedge that all site /or project spa {fIC
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<br /> airly,charges associated with.this�'facitlty o, r'activityf Will be.biltej to'the party identIfled'as" he BILLING PARTY on_.,;,,
<br /> this form. 7
<br /> rMy that 1 have prepared this nrptIcation and that the work to be performed witI be done In accordance with ell SAN
<br /> 1Y Ordinonce Codes aril Standards State end Federal laws
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<br /> �S SIGNATURE
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<br /> ll�nf'r Date
<br /> TION TO RELEASE INFORMATION: ' In addition to the above; when applicable, 1, the owner, operator or agent of.seme 'of
<br /> rty located at the above site address hereby authorize the release of any and all results, geotechniC date and/or
<br /> Intal/site assessment Informatlon,to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as too as
<br /> 1 lebte and at the same time -1 t Is provided to me or W representative: ',
<br /> f Service ReQ�est: t Service Code r'r M
<br /> ,to ,` s�r'l--�TTrf)Icyee ' 7� of 'Ili t bete'
<br /> vlca Completed ' further Action Rewired ;a �'tfr/ N'f y. PROGRAM ELET4EIfi z
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