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1 <br /> SERVICE REQUEST UN OD hl) Revised 8/23/93 <br /> IACILt IT ID / RECORD ID 1 C, I C1 79'3 INVOICE S <br /> MILLING PMTY •Y• / N <br /> FACILITY NAME + <br /> SITE ADbaEft 100 E. Lodi Ave. <br /> Elf? Lodi, CA ZIP 95240 <br /> OUNER/oPERAIOR Kevin Reilly I BILLING PAN Put N <br /> Fluid Manufacturing, PHONE et t 209 1 334 6144 <br /> DBA <br /> ADDRESS 100 E. Dodi Ave. PHONE S2 < > <br /> city Lodi, STATE CA ZIP 95240 . <br /> t-�AnN a ®�1 Lard Use Applleat lass R •� <br /> I I BOS Dist <br /> Locotlon Code <br /> r <br /> CoNISACIOR and/or Jiin'Thorpe Oil, Inc. <br /> SERVICE REOUESICNt BIlLINO PMtT T / <br /> rr 11 1+ // PHCHE 01 t 209 1368 ..6175 - <br /> DBA <br /> P.O. Box 357 fAX ( 209 )368 :1851 <br /> HAILING ADDRESS <br /> city Lodi STATE CA zip 95241-035.7 <br /> BILLING ACKNONLEDGEMENT2 1, the undersigned owner, operator or agent of some, acknowledge that all site and/or project specific <br /> PIIS/EIIU hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br /> Page I of this form. <br /> I oleo certify that I have prepared this application and that the work to be performed will be done In accordance with all BM <br /> JOAOUIN CLUHtT Ordinance Codes and Staedsrds, State -ede,el laws. <br /> APPLICANT'S SIGNATURE 1 <br /> De Dee: 5/26/98 . <br /> vete: Contractor <br /> AUTHCRIZA11O1 TO RELEASE INFORMATICNI, In addition to the nbove, when applicable, .l, the owner, operator or agent. of so", of. <br /> the property located at the above site address hereby outhorlte the release of any and all results, gaotechnfcoI'date and/or z`: <br /> smlrornentel/site ssseesment Information to SM JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALIN DIVISION as soon n <br /> It to available and at the gems tine It Is provided to me or my representative. <br /> U 5.— , p y r.p c�Q Service Code <br /> Netura of Servlte'(Req�utt l ('��., <br /> Assigned to 1� CT's`- _�PI : XZJ•D"t�1ENPloyae 1 I -I, Date _, /.�s,�L,./ <br /> Date Service Cmvitted / / Further Action Required: T / N PROGRAM ELEMENT <br /> Fee Amount AowuntPeld Date of Payment Payment Type Receipt 1 Check if Aeevd By.., <br /> •cue 1 �. / C. / SIPV _,__/_ ACCT _,/_/ UNIT CLK •�'/�_/_ <br />