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',R 43 o.7v f <br /> SERVICE REQUEST --ZnRv taj"REV1"4M-5113191—, <br /> FACILITY ID # RECORD ID # BILLING PARTY Y <br /> A:O 44 <br /> VALLEY WHOLESALE DRUG CO . , INC . f111�� <br /> FACILITY NAME <br /> s•, SITE ADDRESS 1401 W .' FREMONT STREET <br /> STOCKTON , CA zip 95203 <br /> Ci <br /> '�OTjNER/OPERI{iOR,, T 1 nlITS F . SHONEFE __ BILLING PARTY <br /> _.,....... ",.. +DBA -' VALLEY ',WHOLESALE DRUG CO . , INC . PHONE M1'(209 ) 466 - 0131 <br /> '+"i6DRESS � 1A01 LI FRT=MnNT- STRFFT _ _ PHONE #t ( ) <br /> 'k'CifY, ST Q GKTON STATE CA zip 95203 <br /> APN b Census BOS Dist Location Code' City Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR J BTLLING PARTY Y JI N <br /> DBA - -1-`Jr-�-� 'tel C. �1 _ PHONE #1 (ac:-90 G�OV- G <br /> MAILING ADDRESS J'oh 3 s7 FAX # (go -)•�G <br /> CITY _ STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that ail site and/or project specific <br /> PNS/EHD hourly charges associated with this facility or activity wit l be bitted to the party identified as the BILLING PARTY on <br /> Page t of this form. <br /> 1 also certify that I have prepared this application and that the work to be performed alit be done in accordance with att SAN <br /> JOAQIJIN COUNIY ordinance Codes St ards, te-aril Feder' <br /> eder t <br /> (+APkiCANTIS SIGNATURE :1 <br /> rTlttv:t4 CEO Da ( x/9/94 <br /> AUTIrOR[2ATION TO RELEASE INFORMATION: in addition to the above, when appiicabie, T, the owner, operator or agent of same, o <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environental/site assessment Information to SAN JOAQUIN .COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> n <br /> it is avaliabte and at the same time it Is provided to me or my representative. <br /> Mature of Service Request: ; L �C cls,U Service Code <br /> Assigned to 16LA 61,"ele Employee # Date / 1 <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> 13- sl) <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 3 <br /> UNIT CLK _I J <br />