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SERVICE REQUEST (SERVREQ) Revised 5/13/43 <br /> FACILITY ID # RECORD 10 # BILLING PARTY <br /> FActLiTY NJINE VALLEY WHOLESALE DRUG CO. , INC . <br /> siZ'A90 Ssj 1401 W . EREMONT STREET <br /> CIT�� STOCKTON, CA ZIP 95203 <br /> f�E/0PF;TOR -" BILLING PARTY Y / N <br /> VALLEY WHOLESALE DRUG CO . INC . + <br /> 9�y PHONE #i� (2 0 9 ) 4 6 6 - 0131 <br /> i .w.�,i,nF r <br /> DRESS 'An' iA' FRFNIONT STREFT PHOIiE 02 ( ) <br /> CITY 2 r51OCKTON STATE CA zip 95203 <br /> APR # Census --------- BOS Dist Location Code City Code ------ <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR .J i ►ti�.� - 8lLLING PARTY Y / N <br /> DBA K.� B t PHONE #1 *? i.3 <br /> NAILING ADDRESS 3 S FAX # <br /> CITY D� STATE -- zip ��L 7 d I •-43� <br /> N <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned+owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY an <br /> Page 1 of this form. <br /> I also certify that I have prepared this application and that the work to be performed will be dale in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes St rds Feder a - <br /> PU' T#S SIGNATURE :t <br /> � is4=tf <br /> CEO <br /> : 5/9/94 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> ,environmental/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: Service Code <br /> Assigned to Employee # Date <br /> Date Service Completed / f Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> h ` <br /> SUPY _/_� ACCT _/ / UNIT CLIC _/��1 <br />