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I SERVICE REcxlEst -' (EN Ob bi} Revised B/Z3/v3 <br /> 1Ny010E # <br /> RECORD iD 0 <br /> :SL1TY 1D 33 ;�. <br /> iI BIC�LiWG PARTY Y / <br /> M <br /> 01.11Y NAHE TereSi TruCkin .i <br /> :ITE ADDRESS goo 1/2 E. Victor Rd. <br /> City <br /> Lodi CA zip 52+0 <br /> � B1�LLIN4 PARTY y-J/ <br /> N <br /> si Truckin <br /> .R/OPERATOR Tere <br /> DBA _ <br /> PHONE <br /> ADDRESS900 1 2 E. Victor Rd <br /> STATE A -- zip <br /> city Lodi <br /> =APN g Lend Use Application * -1:1'!; Dist Location Code <br /> .R b <br /> B1LL1H4 PARTY Y / <br /> JtRhCTDR end/or Jim Thorpe Oil , Inc. <br /> RVICE REOUESTOR <br /> PHONE gT ( _) --'- <br /> DBA <br /> FAX A (_2 g) <br /> 11LlNG ADDRESS P. 0. Box 357 ; <br /> clry Lodi , <br /> STATE CR zip 95241-0357 <br /> or agent a# same, acknotwledge '',�thet all site and/of, project specific <br /> ACKNM&EDGEMENT1 1, the undersigned owner, operatorart identified as the BiLLiNG PARTY on <br /> i ORO ! be billed to the p Y <br /> 9 activity wil <br /> facility or <br /> pHS/ETR] hourly charges associated with this Y <br /> page i of this form. ;} <br /> f. erformed will be done in accordance with All SAN <br /> f i also certify that I have prepor this application and that the work to be p <br /> L <br /> d0Act11N COUNTY ordinance Code a S ndards, a and deret laws. <br /> i <br /> APPLICANT'S SIGNATURE <br /> i <br /> Date: <br /> Title! Contr t= <br /> when applicable, 1, the owner, operator or agent of Sema. °# <br /> AUtNOR12AiION TO RELEASE INFORMATION: in addition to the above, geotechnical date end/or <br /> the property located at the above site e�to SANess ereby f0AoU19 C8rite the 0lfpTY PUBLiCIREAL114SERVICeny,aES ENViRdNMEemse of NTALHEALTH DIVISION sa soon es <br /> t site assessment Information <br /> environments / <br /> It is available end at the same time it is provided t° me or my representative. <br /> _ Service Code <br /> fA9791gneld <br /> ervice Request: <br /> / —_-- <br /> °[ bats <br /> Employee IV <br /> Date Service Completed <br /> Further Action Required: Y ;J/ N ;� PROGRAM ELEMENT <br /> i? <br /> " Check # Recvd By <br /> Date of Payment Payment Type Receipt R <br /> fee Amount Amount Paid <br /> i� <br />