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,307U <br /> SERVICE REQUEST �� � ilVREQ] R�Vf3gtf 311374] ---'1 <br /> FACILITY ID 0 RECORD ID 0 BILLING PARTY <br /> r <br /> r <br /> VALLEY WHOLESALE DRUG CO , INC �,�,�� <br /> FACILITY NAME ff <br /> +SITE ADDRESS1 1401 W . FREMONT STREET <br /> ' 1"CIT� STOCKTON , CA ZIP 95203 <br /> I <br /> 1q"E'R'1OPERAT0Rj BILLING PARTY T / N <br /> ,• DBA VALLEY WHOLESALE DRUG CO , INC piim cr (. 09 ) 466 - 0131 <br /> ' 'e'ADDRESS,ILl01, tat. FRFMnNT STlTFF_T - ----.-.___--- PHONE A2 <br /> ' yCirY STACK JON STATE CA zip 95203 <br /> APH b Census BOS Dist Location Code City Code ------ <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR J I e g— (9, -2 BILLING PARTY T / N <br /> DBAWL <br /> ' GJ I f .. t ! ( :& � � <br /> r <br /> HAILING ADDRESS (� /J C'h J J FAX $ (gPg-).3r- <br /> CITY � STATE --„�=�r'-- ZIP 2-6-2 <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 bitted to the party identified as the BILLING PARTY on <br /> Page t of this form <br /> ' I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes St ardte-and Feder t-la p <br /> ' {,'APPLICANT+S SIGNATURE •1 •r <br /> --- _ - <br /> �It4e:�# CEO Do f 5/9/9/1 <br /> I� AUIIIORIZATION 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 WEALTH DIVISION as soon as <br /> It Is available and at the same time It Is provided to me or my representative <br /> ' <br /> �C�1 U,�Nature of Service Request, Service Code R, . _. _ <br /> - I <br /> Assigned to !1141 Ui 'oZe iEmployee 0 �J�� Date <br /> Date Service Cmpleted / / Further Action Required- Y / N PROGRAM ELEMENT ;?5 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt A Check 0 Recvd By <br /> l (-n oo <br /> ' 1REHS SUPV ACCT / / UNIT CLK / / <br />