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SERVICE REQUEST EHOO61 SR revised 09/04/98 <br /> I <br /> Type of Business r oeITY D# SERVICE REQUEST <br /> P # _/ <br /> t�u��'m�bile Lube Center FACIL <br /> OWNER OPERATOR BILLING PARTY kAt <br /> Don and Celia Nathe <br /> FACILITY NAME <br /> Airport Wa Lube <br /> SITE ADDRESS 442 N. Airpor tWa�y <br /> 54rrt NumMr OYeala . <br /> Mailing Address (if Different from Site Address) 1632 Oxford Way <br /> Cm Stockton, STATE CA ZIP 95204 <br /> PHONE fN <br /> (209)943-7134APN# LAND USE APM"TION# <br /> ee. <br /> SOS DISTRICT LocAnaN CGDE <br /> PRONE 92 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> BILLING PARTY❑ <br /> REQUESTOR Jim Thorpe Oil , Inc . <br /> PxatE# off. <br /> BUSINESS NAME (209)368-6175 <br /> FAX# <br /> MAILINGAOoRESS P.O. Box 357 I (209\06o 10" <br /> - <br /> CITY Lodi , STATE CA 7JP 95241-0357 <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 SEANCES ENVIRONMENTAL HEALTH OMSION hourly charges associated with this project or activity will be billed to <br /> me or my business as identified on this torn. <br /> I also certify that I have prepared s appli nd th the work to be performed will be done In accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards,ST pd FE L I DATe 3/13/00 <br /> APPLICANT SIGNATURE: Contractor ' } <br /> PRCPERTYIRUSINESSOwNuu <br /> ER ❑ GPEPATOR I MGFR C] OTHER AUTHORIZED AGENT iirrs <br /> ifAPRJCANrs not Un Rrrnr Purrv,proof ofaudrorvieon to sign is rpuired .. - <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, 1, the owner or operator of the property located at the above site address. <br /> hereby authorize the release of any and all resuMs, geotechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION as soon aS it is aVailable and at the same d"it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ample of remote fill lines _ <br /> COMMENTS ElSPEmCONDmON(5)OFAPPROVAL❑ OTHS 11 <br /> RECEIVED, <br /> MAR 142000 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> CNARONMENTAL <br /> I CO SIG TORE: - DA <br /> SIGNATURE: i I — <br /> INSPECTOR'S f <br /> EMPLOYEE#: C— <br /> ,6 1 DATE: 3 1 <br /> APPROVED 9Y: <br /> EMPLOYEE#: Q DATE: <br /> ASSIGNED TO: <br /> SERvICE CODE: <br /> Date Service Completed (if air a completed): 3 payment ate r <br /> Fee Amount Amount Paid <br /> Recelyed Sr. <br /> Payment Type <br /> klvolee# Cheek t L 3 <br />