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SERVICE REQUEST ERVREQ) Revised 5/13/93 <br /> i l 11 <br /> AGILITY ID # RECORD i0 # h 1 1N TY / N <br /> AID # <br /> FACILITY ?LAME /�I}�/CJ� <br /> SITE ADDRESS C/ (� / I FAC # <br /> CITY L o6 J CA ZIP �� # <br /> LZt <br /> OWNER/OPERATOR 71%,2G BILLING PARTY <br /> DBA ' PHONE #1 <br /> ADDRESS C/ / L�� PHONE #z <br /> CITY Lei'l STATE ZIP <br /> APN NCensus - --- 905 Dist Location Code City Code ----- <br /> i r <br /> cDNrRAciaR and/or Jim Thorpe Oil, Inc. <br /> SERVICE REOUESTOR BILLING PARTY Y / <br /> Rich-Mart Construction j 209 368-6175 <br /> DBA PHONE #1 ( ) <br /> MAILING ADDRESS P.O. Box 357 ( 209 ' 368- 851 <br /> Lodi CA <br /> j;9524,T-0357 1,Ell <br /> CITY STATE ZIP p !'? +~ o <br /> 4 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge t !`aLi.,aWe'andldclij�;Iect specific <br /> PHS/END hourly charges associated with this facility or activity will be bitied'to the', Per yy�� , f <br /> PARTY on <br /> Page 1 of this form. V1 �4€ 1� 1��LLl1U1'r <br /> �i <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, ate and Federal laws. ;I <br /> APPLICANT'S SIGNATURE 17 1 <br /> L� ' � y <br /> Title- I �<< r ' Date: <br /> { <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 andallresults, geotechnical data and/or <br /> environmentat/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 /> Nature of Service Request: i �� U U L iY Service Code <br /> Assigned to �1�/C / �GiEiU�} Employee # G Q�= : Date <br />` Date Service Completed / / Further Action Required: Y' / N PROGRAM ELEMENT <br /> k <br /> a <br /> fee Amount Amount Paid Date of Payment Payment Type if Receipt # Check # Recvd By <br /> .1 <br /> E <br /> QU e'�� .SOD E _2 <br /> n 5 <br /> f <br /> RENS <br /> / / SUPV �/ / ACCT 4-1- UNIT CLK �/ / <br />