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SERVICE REQUEST �' EHOO61SR revised 09/04/98 <br /> Type of Business or Property FACILITY ID# SERVICE Rel T a7 <br /> Rail Road Yard 25 X <br /> OWNER OPERATOR BILLING PARTY <br /> Central California Traction Comlinny <br /> FACILITY NAME Stockton Yard <br /> SITE ADDRESS 1645 Ckeeee <br /> str Numeer Di�aceon mw TYO�'" sw.9 <br /> Mailing Address (If Different from Site Address) <br /> Cm Stockton, STATE CA Zw 95205 <br /> 466-6927 O1• APN# LANE)USE APPLICATION# <br /> PHONE#2 EV. BOS DlsrxlcT LOCAnON CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR Jim Thorpe Oil , Inc. BILLING PARTY❑ <br /> BUSINESS NAME PHAON1 2 # Em <br /> 368-6175 <br /> MAILINGADDRESS P.O. $OX 357 F GU 368-1851 <br /> CITY Lodi, CA STATE CA95241-0357 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br /> and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project or activity will be billed to <br /> me or my business as identified on this form. <br /> I also certify that I have prep r dt�t� application and that the ork to be performed will be done in accordance with all SAN JOAOUIN COUNTY <br /> Ordinance Codes, Standard , of FEDE laws. <br /> APPLICANT SIGNATURE: DATE: 12/11/98 <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MAA OTHER AUTHORIZED AGENT (3 Contractor <br /> IfAPPucwT a no(the 8WNG PARTY proof ofauthorizadon to sign is required Tine <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, the owner or operator of the property located at the above site address, <br /> hereby authorize the release of any and all results, geotechnical data and/or environmental/sBe assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Tank Removal Permit <br /> COMMENTS ❑ SPEM COMMON(S)OF APPRWAL❑ DOtet ____...p.--._ ❑ <br /> DEC 14 1 <br /> fAl p M/{fALTIN Co <br /> fA(T OfS <br /> H D 'SIOh; <br /> INSPECTORS SIGNATURE: SIG RE: DATE• <br /> APPROVEDEIY !� EMPLOYEE* DATE: 1,5t <br /> ASSIGNED TO: IC• EMP�_OYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount ( Amount Paid Payment Date <br /> Payment Type Inr,!r # Check# RceeivedI _ <br />