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SERVICE REQUEST <br /> Type at Business or Properly FACILITY ID SERVICE REQUESTS <br /> 0mmercia SR 33031 <br /> OMW OPRrATGR Sum PARrY <br /> Iwo ( W: Isom <br /> FALYm NAME <br /> SimAwRos <br /> I A'i r P o Ir+ W Q <br /> sa.ssose. a� e.e�. To. am.s <br /> lIng Address (it Difffrom Site Address) <br /> D3S' 0 c n Yl 6L -e-. <br /> cTr )-DS Rrl � luS <br /> P'MNEtt IS-- ` cr APN3 I� _ IK 1 lb� LwoUsEAvwxanaxT <br /> P4EI m aCSCrsrlar - LCc�TnxCCCE <br /> ( — 20& ; <br /> CONTRACT CR I 5Vw(VCE REQUESOR -- _ <br /> REGUESMR - - �8n'er Pura C — <br /> Jim Thorpe �Oil , Inc. <br /> EMMW NAPE NCRE <br /> 1209) 368-6175 <br /> KmAnAwREssI FAx3 <br /> P.O. Box 357 <br /> CTM Lodi, CA STATE CA ZIP 95241-0357 <br /> EILLMG ACICNCWLc GEMENT: L the wZemW ed PmPOM or business*ww,operamr or auaborcad agem of same, adhlewhedge tlrat as mle muft;mOr-*speem <br /> PueLc HEALTH SFRvr--s Ew poaertx HE+L;H Civom hctnv dmrges YnM d1e propCarztmy va be baled to me army husinass as dwo5ed on To brM <br /> I aim comfy drat I nave preaered this appfiradrn and Tat 719'Mk b be periomed we be done 41 acdance wdh atl SAN.CAr1m1 Carni Cmmars a CadeS.S3ndvft Swe and <br /> FMEPaL!ava. c eK, <br /> AvrUcwr SK wstiaF• V Yil til n� l ' CwtE n <br /> PRCPERTY/SuSNMCWNO X1 CPSATCR/MANAGER C CrRERAun4CF=Aar C <br /> BAMLwranX e&124P. Titre <br /> AUTHCRMMCN TO RELEASE INFORMATiCN:When ap0mble.L 7e awnr ar opsr�u 7e property faabsi at 7b above sib addrffis.hcehy avdlmizs 7e rerease of <br /> any and ad resuft geowamx f data and/or wzvianrtw=lltib assesanem Atmadml to ft SAN Xwm C:wM Pum 4FALTN S�X3 Ewmmefrx HEACH Cn=a as soon 31 <br /> as 7 is available and at 71e sane frtm d s pmvided to me or my mpmsamtw& <br /> TYPE of Sa a–c RECUESTEO: - E <br /> Tank Removal PermitPAYM ED <br /> OaerErrs. <br /> MAR 1 1 2003 <br /> SPUBU�NOA jH PRHU�S10N <br /> ENNFONMEN <br /> Uwacrojes SIGNATURE CCNrP.ACMIe3 S1GaATURE <br /> APPRCVEU sr. —Z X ,Ul, I LATE 3 _ 1 1 ✓ <br /> As=mm T0: f� LATE 3 - 11 - 3 <br /> Date Service Completed (If afready completed): I SERv1Cc CCCE: 03I P 1'e E07 <br /> ' <br /> he Amount "Z� I Amount Paid tt _,_l. I Payment Dab -? <br /> Payment Type Invoice A Check I �7, - Received fly: <br />