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accvar c RFy]I IFST EHOO61SR revised 09/04/98 Type of Business or Property FACILITY ID # BUMPAarv❑ ES SERVICE REES Roofing Tile Mfg. PNONE{ ee BUSINESS NAME OiIM BILLING PARTY OWNER/ OPERATOR Lavor Thompson FACILITY NAME Ro—Tile CITY Lodi, SITE ADDRESS 310N. Cluff Ave. Met StrM NYmer dnNen SInM Nam. Mailing Address (If Different from SIM Addressl Cin Lodi, STATE CA ZIP 95240 PHONE 1T1LAND "r' APN# USE APPLICATION R (209)369-4751 INSPECTOR'S SIGNATURE: PHONE#2 _ !lt SOS DISTRICT pIR LOCATION OOH. SERVICE REQUESTUR REOUESTOR Jim Thorpe Oil, Inc. BUMPAarv❑ Tank Removal Permit PNONE{ ee BUSINESS NAME OiIM (209)369-6175 NWLmaADDREss P.O. Box 357 FATtt (209)368-1851 CITY Lodi, STATE CA IJP 9524100357 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent or same,, acRnowiwyc Z"a% — aae and/or project specific PURUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that1 have prep ap on and t Z the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standard ndrtDERAtt 12/20/98 APPLICANT SIGNATURE: DATE' PROPERTY I BUSINESS OWNER Cl OPERATTIR I MANAGER ❑ OTHER AUTHORIZER AGENT ® C o n t r a c t o r NAPRxwrtsnofiheaUJKPARry Prop/o/aufhorhadontosgn isregofred Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentausits assessment infonnatlon to the SAN JOAQUIN COUNTY PI IRI IC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as Soon as N is available and at the Same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Underground 11 Tank Removal Permit COMMENTS ❑ SPECIAL CONOTIOR(S) OF APPROVAL❑ OiIM ❑ CQuNTv PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISTOP. INSPECTOR'S SIGNATURE: CO pIR If DALE: 12/20/98 APPROVED By: ASSIGNEDTO: n/ EMPLOYEE EMPLOYEE#: (� DATE: / z � —9 J Date Service Completed (if already completed): SERVICE CODE: P / E: Fee Amount: Amount Paid Payment Date Payment Type Invo I Recelyed By: