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r .. <br /> SERVICE REQUEST .rr..91M=TIY <br /> RVRE0).Rla/. <br /> FACILITY ID N RECORD to / MINAG <br /> : r <br /> WME <br /> fActllt+l NAME Sears Roebuck & Co. [! F #ter <br /> 1I11 ADbRlBl 5110 Pacific Ave. _ _ :iV # <br /> Stockton, 95207 i <br /> ` ttT CA ZIP <br /> Sears Roebuck & Co. <br /> MA/OPERAlot BILLING PARTY / ,N <br /> IrDBA <br /> TA -hiss 2100 N. Tustin <br /> Orange, CA 92655 <br /> '•, �itY • � � ► STATE IEP <br /> APR a Census ----•---- 130S Ofet• Location Code City Code •=••-- <br /> CONTRACTOR and/or Jim Thorpe Oil, Inc. <br /> SERVICE REQUESTOR BILLING PARTY Y / N <br /> DBA Ric} -Mart Construction PHONE 01 800 ) 844 6175 <br /> HAILING ADDRESS <br /> P.O. BbX 357 FAx A (209 ) 368 185 1- <br /> city <br /> LodiSTATE ZIP, CA 95241-0357 <br /> OWING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or:project specific <br /> PHS/EHO hourty charges associated with this facility or activity will be billed to the party Identified as•the.BILLING PARTY on <br /> Page I of thlt form. + <br /> I also certify that t have prepared this application and that the work to be performed will be dans In Accordance with all SAN ' <br /> JOAQUIN COUNTT Ordinance Codes Standards, Sate and Federal taws. ti <br /> wAPOUCANT10 BIGNATURE t� <br /> Dates-1 } ' <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 date and/or <br /> environmental/slte 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 /> NaturA of Service Requests 2A- q Service Codep3y # <br /> Assigned tO _ Ld" I _. Employee R Date <br /> Date Service Completed Further Action Requlredw Y / N PROGRAM ELEMENT 3, <br /> a . <br /> fee Amount Amount Paid Date of Payment Payment Type Receipt X Check B Recvd By <br /> rk <br /> RENS <br /> _/_1 SUPV _J / ACCT / / JUNIT CLK �/ 1 <br />