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_ 3 o v SERVICE REQUEST SR� Z3'irRVlZi:tT�"RLNtHEd`?rt319]— ILFACILITY ID R RECORD IDR B1LL[NO PARTY `FACILITY NAME VALLEY WHOLESALE DRUG CO. , INC . IOv # rSIYE ADDRESS1 1401 W. FREMONT STREET 1,C1 STOCKTON, CA ZIP 95203 T� Lt,4. yi r O11NER/OPERJITOR+ BILLING PARTY ;D$A VALLEY WHOLESALE DRUG CO . , INC . PHONE iIQ{209 > 46b - 0 13 1 "lly�'ADDRESS* PHONE #2 ( ) STOCKTON _ STATE CA zip 95203 APR p Census --------- BOS D[st Location Code City code ----_- CONTRACTOR and/or SERVICE REQUESTOR _.*-S 1 t'�n. I i1�yr �/�, L BILLING PARTY Y / N DBA LC.� Q ICJ / PHONE #1 (2" MAlLIND ADDRESS l ph S FAX S CITY STATE ZIP -S 2 BILLING ACKNOULEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. I also certify that 1 have prepared this application and that the worst to be performed will be done In accordance with oil SAN JOAQUIN COUNTY ordinance Codes St ords,_5iate-and Feder 1'Za 1 APPLICANT'S SIGNATURE :f C �� eTItJoit' CEOy` Da :f 5/ 9/94 AUTHORIZATION TO RELEASE INFORMATION- In addition to the above, when applicable, 1, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmentat/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION es soon as It is available end at the same time it is provided to me or my representative. Nature of Service Request: C c)�Ut`' a Service Code Assigned to 14 _ [/i.DZ�f 7�7- ., Enployee R ��/„ _ Date Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 3 PL) Fee Amount Amount Paid Date of Payment Payment Type Receipt R Check R Recvd By SUPV �/ / ACCT _/ / UNIT CLK _/ /