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).. <br />Type of Business or Property Lube Center <br />OWNER OPERATOR Raymond Lop <br />FACIuTYNAME Air Port Wa <br />SITE ADDRESS 442 N. <br />Str N hV oin°N" <br />Mailing Address (If Different from Site Address) <br />Cm Stockton, <br />PNBPT 462-0253 <br />t ) <br />PHONE #2 <br />FACILITY ID <br />ez <br />Way <br />STATE CA <br />APN 4 LAND USE APPLICATION # <br />BOB DISTRICT <br />v�nc ocnr IFCTf1R <br />SR <br />BILLING PARTY 11 <br />ZIP 95205 <br />LOCATION CODE <br />V Vl�ln/.v.v..•v . <br />TYPE OF SERVICE REQUESTED:. <br />BILLING PARTY <br />REQUESTOR Jim Thorpe Oil, Inc. <br />COMMENTS ❑ SPECIAL CONDmON(S) OF APPROVAL❑ <br />OTHER <br />PHOHE:' <br />BUSINESS NAME <br />PUB <br />P09 <br />368-6175 <br />ERb'CFS <br />A'I`hTALhu1 <br />FAX$ <br />Drv131<�;. <br />MAILING ADDRESS009 <br />P.O. Box 357 <br />368-1851 <br />STATE CA <br />ZIP 95241-0357 <br />CITY Lodi, <br />NA <br />t DATE: 12/8/98 <br />that all site <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or busmess owner, opelmel v. _. ___._,. -_-- _ <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 th form - <br />I also certify that I have prep t pI tion th ork to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br />Ordinance Codes, Standards a F aws. <br />APPLICANT SIGNATURE: <br />DATE 12/8/98 <br />���n <br />PROPERTY BUSINESS OWNER Cl OPERATOR/ MANAGER ❑ VIf.�T AUTHORIZED AGENT Ig]ContractorTitle <br />IfAPPuCAVT B not the BWNG PARry pmofaf �udwraation m sign is required <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 environmentaVsne assessment information to the SAN JOAQUIN COUNTY <br />CvowiCES FuvionuuvurAl_ HEALTH DIVISION as soon as it Is available and at the same time it is provided to me or my representative. <br />1 <br />TYPE OF SERVICE REQUESTED:. <br />.Tank Removal Permit <br />COMMENTS ❑ SPECIAL CONDmON(S) OF APPROVAL❑ <br />OTHER <br />A".SGA ❑ <br />PUB <br />ERb'CFS <br />A'I`hTALhu1 <br />Drv131<�;. <br />NA <br />t DATE: 12/8/98 <br />INSPECTOR'S SIGNATURE: <br />a/ <br />EMPLOYEE ft: <br />DATE: <br />APPROVED By: - <br />EMPLOYEE <br />DATE: <br />ASSIGNED TO: �-(� <br />Date Service Completed (if already o feted): <br />SERVICE CODE• <br />P ! E: <br />Fee Amount 3 ' �� Amount Paid <br />Payment Date <br />Payment Type i"- Invoice <br />Checktk - <br />Received By: <br />.— —�- <br />1 <br />