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SERVICE REQUEST <br /> Type of Business or Property FACMY IO# SERVICE REQUEST# <br /> Vaccant Lot S/L0O�261�2-3 <br /> OWNERI OPERATOR Bujur PARTY r. <br /> The City of Stockton , Redevelopment Agency <br /> FActu y NAME <br /> SiTEADORESS 310 S American .: t <br /> SA. 4N . ai: . � NLm TNS seams <br /> Mailing Address (if Different from Site Address) 22XZXXNKKK fXAXK 305 N. E1 Dorado St . , Suite 200 <br /> CITY Stockton, SATE CA ZIP 95202 <br /> PHONE*1 APN# LANG USE APPAL ATION# <br /> (202 937-8320 <br /> PNONE#2 - - rN -- SOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> RECUESTOR BILLING PARTY❑ <br /> Jim Thorpe Oil, Inc. <br /> BUSINESS NAME PHONE# aT- <br /> Jim Thorpe Oil, Inc. 1209 368-6175 <br /> MAILING ADDRESS FAX# <br /> P.O. box 357t2O9368-1851 <br /> Crty Lodi , STATE CA LP 95241-0357 <br /> BILLING ACKNOWLEDGEMENT: I.the undersigned property or business owner,operator or authored agent of same.admamedge that ail Sita and/or POjeG sceeec <br /> PUSUC HEALTH SERVICES EWRONMENTAL HEALTH Ow;cN hourly charges amoeated with this project or activity will be billed to me or my business as'denfified an this fcna <br /> I also cerdy that I have prepared s app( tion an at Ne work to be performed will be done In acardance with all SAN JOAQUIN COUNTY Crdmance Codes,Standards,SATE and <br /> FEDERAL laws. <br /> APPUUNr SIGNATURE: L/ DATE: • ` r�L7 2-- <br /> PROPERTY/BUSINES <br /> -PROPERTY/BUSINESS OVMER C OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> HAP -ewrsnditll&LrPu_proalofaud"zodam h.tiinis required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When appficeble,I,the ownerar operator of the property kited at the above site address,hereby autharmeNe mlease of <br /> any and all results,geoteUtniaal data and/or emvanmentadsie assessment infannaton to the SAN JOAQUIN COUNTY PUBLIC HEALTH SET -S EmaCNmtrAL HEAL.H Orv@CN as soon <br /> as it is available and at the same time itis provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Underground Tank Removal Permit N� <br /> COMMENTS: <br /> Pp�`oH PNEP NO�S,r,;�. <br /> c T�`nSl <br /> INSPECTOR'S SIG RE CONTRACTORis SIGNATU <br /> APPROVED Eir EMPL- 2. /� DAA 4/29/02 <br /> ASSIGNED TO. �, 'E,1 EMP=m#: Qq8 a DATE: 0 Z o <br /> Date Service Completed [If ready completed): - SHtHCECaDE -- 'PIE�3a- -- <br /> Fee Amount Amount Paid -5 JO-7 6D Payment Osie <br /> Payment Type Invoice Check# J- Received By '�_ <br />