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can oo b1� Mwleid�1t�I :� <br /> •r 9EIIVICE REaUEBTomits 0 , <br /> '��"t <br /> ------------------------ <br /> b4j _ I1i <br /> Tri"Star Homes, LLC BILLING PARtY <br /> FActt i tr WANE <br /> 1 <br /> 1325 N. Corral Hollow Rd. <br /> Otte ADDRESS ;' I <br /> n of s <br /> Tracy, CA 95736 zIP I <br /> Clir <br /> Tri "Star Homes «ILLINN PARTY <br /> bt>f1ER/OPERAIOR �"';K ': <br /> :. .<. . <br /> 'PRONE O1 (51.0 ) — ` <br /> b9A <br /> P.0. ' Box 1056 "on rz <br /> ADDRESS ` <br /> Alamo, CA 94507 STATE <br /> CITY <br /> tend Use Applieetion / <br /> APN / 6os olat Laeetfan Code <br /> toNTRACTOR and/or Thorpe Oil Inc. tlitLlNB PARTY r: / <br /> SERVICE REOUESTOR `� <br /> ' I <br /> PNONE If1 I.2{'Q. <br /> NAILING ADDRESS <br /> P.O. Box 357 FAX 0 t 209 )-368 <br /> u <br /> Lodi, STATE CA tp 95241-0357 <br /> ' - CITY <br /> rotor or agent of a ackno�iedge that alk elti and/or project epeet�lo <br /> Btttif#fl AC I.:the undersigned owner. cps _ <br /> PN9/END hourly chargee eseoclsted mlth this fecllity or activity milt be bitted to the party Idehtlfiad a PAYME11NN�PARIY <br /> Page 1 of this, form. �� <br /> 1 t; ell th sit BAN <br /> I also certify that t have prepared this application aril that the work to performed mitt be dons InA _�997 <br /> JMQUIN COUNTY Ordlnence Cadee girds. State end F rat tome. SAN <br /> ? .• 4. 3 <br /> , Pi19L JUc,}U�Jy.CCJUNTy ' h,� �- , �! <br /> AI'PtICANT'3 SiGNA1URE � <br /> NM QcmVICES d: r ' �, <br /> 5/19/97 , ENTAL HEALTH DIVISIOlv�s4 <br /> 11 t 1e:: CORt t'aCtOY' a )'YrM, Date! <br /> ''. S v '4a r��#S i'v 3w�3,. _ .. �s •c - ,�: M"' z se4 �'s' <br /> 1,=:< �Y�•_ � w retaeaor egept of creme, of <br /> AU I'M TO RELEASE tNFORHATION: ' In addition to the'above, <br /> when epptf sots.'[. the ewne�, ape <br /> the property located et the.aoove site address hereby authorize the releaseof. errlr and alt results, oeoteehntcet dateaend/or �3r <br /> ,Anvitormm�tal/site eaeeasmnnt informatlon to SAN JOAQUIN COUNTY PU9tic.REAL N SERVICES ENVIRONI NIAL NEALTN DIViB10N es 9ooni N4 �p <br /> lt. is avallebie and et`the�esne time It is prevlded-to me or ay representative. <br /> Nature of $ervlc8 Requestt <br /> 77•n. .^S fix.- � _' ,: .. ltv i `fit <br /> Assigned to E�loyee <br /> �t <br /> k� "5 Further Action Required: Y <br /> AA 6 <br /> bsyte gervlee eonipittcd l I <br /> Fee Amotmt ;Amount Patd bate of Payment Payment. Typo Receipt rf . ChlCk �:. Recvd <br /> a!HS C�� z[. SWV _.....�.^f ACCT u"tr r- <br /> �. • - �: ,:j„_ 5 "`""fes <br /> .•S <br />