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�— SERVICE REQUEST -.. EHOO61SR revised 09/04/98 <br /> Type of Business or Property Trailer Mfg. FACILITY ID SERVICE REQUEST# 11 77 <br /> OWNER OPERATOR Tuff Boy Leasing BILLING PARTY <br /> FACILITY NAME Tuff Boy Trailers <br /> SnrEADORESS , <br /> 55tr^.Yl 1,4. Almondwood ftdNie, rTP. Seim r <br /> Mailing Address (If Different from Site Address) <br /> Cm STATE CA LP 95337 <br /> Manteca, <br /> PHONE#1 APN# LAND USE APPucATON# <br /> �' <br /> 20 239-1361 <br /> PHONE ICI a* BOS Dmaiff l ownox CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REOOESTOR JIm Thorpe Oil , Inc. BILLING PARTY <br /> E t. <br /> Buswss NAME p 369-6175 <br /> MIULMGADDRESS FV0 368-1851 <br /> P.O. Box 357 <br /> Cm Lodi , CA <br /> STATE CA ZIP 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 SERVICES ENVIRONMENTAL HEALTH OrASION 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 p orad 1 applicatio t �Bwork to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standa ST d F;EDL la 12/17/98 <br /> APPLICANT SIGNATURE: t DATE' <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR]MANAGER OTHER AtfnroRlffDA(aENi <br /> ]f APa/Gwr k not#b BV,M PARTY.proof of surhodndon to sign is rpukod Title . <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 environmentallsite assessment Information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVIcEs ENVIRONMENTAL HEALTH DIVISION as soon as it is availah a and at the same time it is provided to me or my representative. <br /> TYPE OF SERVILE REOummn: <br /> Tank Removal Permit <br /> COMMENTS SPECIAL CONDHION(S)OF APPROvAl❑ ER ❑ <br /> PAYIIBE <br /> C-EIVED <br /> ENVIRO <br /> IN HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: C R'S TURF: IDA 12/17/98 <br /> APPROVFDBY: t. EMPLOYEEDATE: <br /> ASSIGNEO TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: d P 1 E: 30 <br /> Fee Amount: 1 �- Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br />