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SERVICE REQUEST • (SERVRE`ql-__I*id 8 <br /> FACILITY IDI— <br /> # RECORD ID # INVOICE # <br /> rAr.ILITY NAME Flying T Travel PTa7,,A BILLING PARTY Y 1 <br /> SITE ADDRESS Jack Tone Road R Hi Q ghwaXy g <br /> 49 Frontage Road <br /> CITY Ripon CA ZIP 95366 <br /> OWNFR/OrERATOR Flying J Inc. BiLLiNG PARTY Y / N <br /> DBA Flying J Tnr, ___ PHONE #1 (R�1 ) 7_34 - <br /> ADDREss 50 West 990 South PHONE #z (801 ) 734 <br /> CITY Bri gl)aM City y STATE .J j-ah zip 84302 <br /> —APN-# —Land Use Application # <br /> � <br /> �—— � BOS Dist location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR Wieser Arch itert�-, BILLING PARTY N <br /> DBA Wieser Architects PHONE #1 (R01 ) 7'id-66400 <br /> MAILING ADDREss 50 West 990 South FAX # (801 )234 - 6507 <br /> CITY Brigham City STATE Utajl zip 84302 <br /> RII.LiNG ACKNOWLEDGEMENT: i, the undersigned owner, operator or agent of same, acknowledge that ell site and/or project specific <br /> PIIS/EHO hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> i also certify that i have prepared this application and that the work to be performed wilt be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Co a ds, State and Federal laws. <br /> APPLICANT'S SIGNATURE E "' <br /> Title: Project Manager Date: May 19, 1994 <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/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 1 <br /> Assigned to ( 4- ti Employee # Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT ; <br /> Fe A t Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RFHS �/ / SUPV —/__/ ACCT `J / / UNiT CLK _/ / <br />