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ihCfilTT 113 0 RfJID / St 0 PARTY V / <br />¢> fACIUTi NAME Sears Roebuck & Co. <br /> Ll <br /> MH "Anil 5110 Pacific Ave. 38q <br /> Stockton, 95207 <br /> �fr CA ZIP <br />;gMPEIlAfdt Sears Roebuck & Co. fj <br /> BILLING PARTY / N <br /> time <br /> AbDAE9lt 2100 N. u s t i n 3-333 <br /> Ora e, 4Z-Z-- STAIE 7V6 1L IIP �2 to0� ?I <br /> APN M Census -••-•---- BOS blst Location Code City Code ••---- <br /> CoNtRACIOR and/or Jim Thorpe Oil, Inc. <br /> SERVICE REOMSIOR BILLING PARTY V / N <br /> DRA Rich-Mart Construction PHONE Irl (800 844 6175 <br /> { <br /> NAILING ADbAESs P.O. Box 357 FAX N (209 . ) 368 - 1851 <br /> CITY Lodi, STATE CA tip 95241-0357 63:, <br /> BIM"(1 ACKHOIILEDGEMENTI 1, the undersigned owner, operator or agent of some, acknowledge that all site and/or,project specific <br /> PHS/END hourly charges associated with this facility or activity wilt be billed to the party Identified as.the•BILLING PARTY an <br /> Page I of this form. ' <br /> 1 also certify that I have prepared this application end that the work to be performed will be done in sccordonc6 with alt SAO <br /> JDAOUIN COUNTY Ordinance codes end Standards, State and Federal laws. ,t'...`, <br /> AvPLICANT11 91o"ATtml I" , <br /> f�llei s CSi ,& , _....... <br /> Dately . <br /> AUTHORIZATION TO RELEASE iur6RMA1I0N: 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 data end/or <br /> enVlrornlentsl/site Assessment Information to SAH JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALIH DIVISION ss soon as s <br /> It is available end at the same time It is provided to me or my representative. <br /> i <br /> Nater! of Service Requests mazai Service Code <br /> Assigned td E�loyee 0 Date <br /> i <br /> bate Service Completed / / Further Action Requiredt Y / N PROGRAM <br /> f . <br /> Fee Amount Amount Paid Date of Payment Peyment Type Receipt R Check N ,lewd By <br /> 6-a961% Tois <br /> RENS �/ / sUPV ____,/ / ACCT / 9 / UNIT CLK <br />