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ti SERVICE REQUEST EH0061SR revised 09/04/98 <br /> Type of Business or Property FACILITY ID# SERVICE`1. / EST <br /> Farm Headquarters <br /> �J <br /> OWNER OPERATORSan Tomo Partners SKUMPARTYK.I <br /> FAcILmNAME San Tomo Partners <br /> SITE ADDRESS 11291 N. Alpines I &d• <br /> Soft R <br /> SNumbs' olw9nn <br /> tr <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP <br /> Stockton CA 95212 <br /> PHONE#1 �T. APN# LAND USEAPPLIGATION# <br /> 2Q9 948-0792 <br /> PHONE#2 Ea. 80S DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR Jim Thorpe Oil , Inc. BILUNG PARTY <br /> BUSINESS NAME PHONE# Exr <br /> 20 368-6175 <br /> MAILING ADDRESS FAX# <br /> P.O. Box 357 20 368-1851 <br /> CITY Lodi , STATE CA ZIP 95241-0357 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 DIVISION hourly charges associated with this project or activity will be billed to <br /> me or my business as identified on this form. <br /> a work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> I also certify that I have prepsPlication d that <br /> Ordinance Codes, Standardsd EDE laws <br /> DAM 12/3/98 <br /> APPUCANT SIGNATURE: <br /> o>�RAumACEN �- Contractor <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR I MNIAGER Title <br /> IfAPPU NrT is mt the BWNG PARTY,proof of audioraadon m sign is requbvd _ <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 environmental/site assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> •Tank Removal Permit <br /> -- <br /> COMMENTS ❑ SPECIAL CONDrTION(S)OF APPROVAL❑ OTHER --"'--� <br /> DEC 7 1998 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SEFM�:ES <br /> R' S RE: I DATE: <br /> INSPECTOR'S SIGNATURE: 12/3/98 <br /> EMPLOYEE#: DATE: q <br /> APPROVED BY. -.. <br /> EMPLOYEE#: a DATE: l <br /> ASSIGNED TO: <br /> SERVICE CODE: PIE: 3 <br /> Date Service Completed (if already completed): <br /> � <br /> g , bc, Amount Paid (0 N Payment Date <br /> Fee Amount: <br /> Payment Type <br /> Invoice# Check 9 Received By: <br />