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FROM z, JIM THORPE OIL, INC. i FAX NO. : 209 368-1851 Jul. 09 2001 11:31AM P2 <br /> S'cRNTCE REQUEST -: <br /> Type of Susiaess or Property FACUrY 10 x . ..-. S'cFmCE^RE�C,UESiI"sw, <br /> S�.oc� 2l,zLp 6� <br /> CiM1E2IOPEiA R .. Sl 2io PAM . <br /> FAamtrr NAME �a ... _....R ...:. ... .... ' <br /> 'o7k �L <br /> 9RMtlm,er we,�e ,. sewer rie. �»s�..�:i <br /> 6failing Address (If OiRerarrt from$ita Add /'1 t , <br /> PNONEr1 E[c - :APN'rC . .. ..._. -.. LVM USEAPPLICATY7Ns <br /> qj <br /> PHONE'aZ E.L ._ SOSOeetse"r <br /> . LccaT10NC00E'. q <br /> _ _ t <br /> REQU SUM= <br /> _... CONTRAC'fORlSE4VICEREQUESTaR '.: :; <br /> � .- <br /> Mau.tNcAoaREss Fax# - <br /> Cm SLATE �2-0 Z ; <br /> BILLING AMOWLEOGEMe?!T: L Cie unde*rmd pmpefip or husinera aweer,cperamr arawlrartx4 agent of same.ad=wi*a Imtat sae andkr prgeetpp <br /> PU&ZHF.AU14$MUMSE^ WV41ENtu.HBUN OM9oMhmrffdnuggssaZ QwipLCtispmje¢araea+ilywi0 be bled to mearmyhvsinessasOmakdm is YamL <br /> I.atsvae*tlmtlhave peepaf¢dtlUaappGrxdan and.CpQoterem�a t>e pedarmed wig hadaneh ac=M TM vNh al sm 1Qab1m Country Ordnmanee Cadea.SNndai ftSm <br /> FMML 2Wm x <br /> APPUtCwtS4alArutt :app: <br /> PNG761TYIBU3¢aS4G'.H+ER '. , � '`'--.O'+Ee*A70t+G IAeNAdet '. Q OneTAUTem+IDaG^c!r <br /> ' - ,,........ ... _.._dAanf;wTisr�lhe&nr.Funv peel ela,damdeeeeagr¢n�ire6 - r!!s' <br /> .AUTHORI2ATIONTO RELEASE INFORMATION:When aapfwable.I.tlteovmeracap�raroraf dre pmpary'ara�aitiseandve.sita addresx IterrbyaMmilsdezn <br /> any and a&rewl�9eCfedadcitdaEa aid/ar�Ntl�i�(�aae5galwKia�l�o6la lhs Sx7lOw7tnRCCtwTY PVBticHF�iUtr�avGSE+�iCN/BtratHEwlt@Al.Waaa <br /> ., as itsava>tabfeaadatRiesametuneitspmvided nrmeormyrepieszermdve: .. ;..."., . `}.` . f"`.. ,:";: >:-.� <br /> TYPt:OF Sawa REMUESTEf7: <br /> CoAtYENry: if <br /> CaxrRacrolYs SIGNATU <br /> Asumm m: OA= <br /> Cate Service completed (rf afrmgd '�,- ,. SF,2vICEC00H 'P 1 E :. <br /> r' <br /> Fee AmourrC / c.�-- Amount Paid /-7q Payment Dant /� �. ... . <br /> Payment Type ✓ Invoice s Check f r S s'�ii - - Re=ived 8y. <br />