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A-i" <br /> ,. . <br /> SERVICE REQUEST (SERVREO) Revised,l8/23/93.x_; <br /> v, <br /> 17 r + : <br /> FACILITY iD A RECORD ID INVOICE <br /> J & L Market ` <br /> rnr.iL1TY HARE BILLING PARTY / ^N <br /> , <br /> SITE ADDRESS , 8115 SOLIth El Dorado Street <br /> cITY French Camp cA u zIP- -95231 <br /> OLNFP./OPERATOR : .James Fisk BiLLiNG PARTY ;. T / <br /> DBA Market PHONES 209 '9 _ _ <br /> 0 82 0897 <br /> ADDRESS 8115 South EI Dorado Street PHONE #2 <br /> cltr French Camp STATE ' Ca -ZiP 95231 <br /> -APN W -Land Use Application <br /> SOS Dist Location Code <br /> .CONTRACTOR and/or <br /> SFRViCE.REQUESTOR Flite IV Contractors Attn: Tim Gipson BILLING PARTY <br /> t <br /> DBA PHONE *1 (�§ ) 461 $337 r <br /> HAILING ADDRESS n u - FAX of (�n4 _) 461 -1342 <br /> 273 Te gri��J�p,+' r <br /> Ci TY' "� a6�4i nn STATE _ ZIP �� <br /> BILLING ACKNOWLEDGEMENT: ' 1,'the undersigned owner, operator or.agent of same, acknowledge that-all site and/or project specific <br /> PHS/END hourhy charges associated uith..this facility or activity will be bittedtothe party identified as 6h:41 LLING PARTY on <br /> ". Page'1 of this form. ' <br /> i also certify that t have prepared this application and that the work to be performed will be done in accordance with all SAN -- <br /> JOACUIN COUNTY Ordinance Codes and Standards, State.and Federal laws. <br /> 'APPLtCANT�S.SIGNATURE <br /> Title- Owner y, Date: <br /> AOTHORIZATION TO RELEASE INFORMATION: 1n addition to the above, when applicable, i, 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 /> environmental/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. - <br /> Neture'of Service Request: Service Code, <br /> Assigned to Employee Dete.. - <br /> =_ - <br /> Date Service Completed ' % / -. Further Action Required .Y y /: N PROGRAM ELEKEWT <br /> Fee Amount _,7 Amount Paid r� Date f PeymenL�� eyme+Tt Type Receipt{atitz rChecy � . <br /> } cit f By t . <br /> '{`r " '�-s i} ti4? M. 1'"ay. Y�.s o. >r",Z�,'',r `l.Yk. T •- <br /> r 7t' � "� gn :1 1 i h 1. .xr 4•'�`.a.��dS'•�; ..�7^u. fir• �:�� 1,!"�t�Y".�" ,F6. r• <br /> �� € ,t. x- 1'.�}:._=�.LS.:.:r�.- .�':-�.11�'� �" SF.�rs _� :�5�6':.. ,.•:fir -fir, ar�•�:.a.,_e .;�#f.'� ' <br /> r ..�. y�„,r_i E•�s_..-Y iS � r -i;'••Y �MiiR <br /> t ,1 +. i ■ i� "`j"t'y t tF" r ii,,;-2 fpnl',fS'"�a " .� `l''`. Lx 4`i do y 1 <br /> -,qV <br />