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:RVICE REQUEST EHOO61SR revised 09/04(98 <br /> Type of Busine a r perty FACILITY ID# SERVICE REQUEST# G <br /> rm <br /> OWNER OPERATORC BIL PA <br /> Lorraine Solari <br /> ,j (� <br /> FACamNAME Solari Clements Ranch <br /> <,. <br /> SITE ADDRESS 17815 N. Highway 88 <br /> SO.M xae. <br /> Stree xwMr Wrrlee Z7-;" <br /> Mailing Address (If Different from Site Address) 13801 E. Eight Mile Rd. <br /> CITY Linden, CA <br /> STATE LP 95236 <br /> PHONE 9H Exr. APN# LAND USE APPLICATION# <br /> ( 2 09 931-1444 LOCATION CODE <br /> PHONE#2 e•*- BOS DISTRICT <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> Jim Thorpe Oil , Inc. <br /> Esc <br /> BUSINESS NAME 368-6175 <br /> MAILING ADDRESS P.O. Box 357 2 F # 9 368-1851 <br /> - <br /> Cm Lodi , STATE CA ZP95241-0357 <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 DMSION hourly Charges Bssoddsd 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 prepared IN applicelion th in Work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codas, Standanls,�9fA Ind FEDE _ 10/30/ 0 <br /> APPLICANT SIGNATURE: DATE. <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTNER AUTHMM AGENTdam— <br /> If APPUGWT is not fire BI UM PARTY Proof of authorhadon to sign Is required 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 environmentaUsite 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 /> HAY VII EN-i <br /> TYPE OF SERVICE REQUESTED: RECEIVE C <br /> • Tank Removal Permit []� <br /> COMMENTS ❑ SPECIAL CONDIION(SjOFAPPROVAL❑ OTHER 2000 <br /> SAN JOAQUIN COUN-I <br /> PUBLIC HEALTH SERVICF'_ <br /> ENVIRONMENTAL HEALT. <br /> INSPECTOR'S SIGNATURE:, R'SS RE: DATE: 1Q/30/00 <br /> APPROVED err GC�/ ALr4 Z EMPLOYEE,;: �no'ZI�J DATE: 0 <br /> AssiGNEOTO: �'�,� L(��.R. EMPLOYEE#: loam DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3 L ' P I E: <br /> Fee Amount: j Amount Paid 7— b Payment Date <br /> Payment Type Invoice Check Received Sy: ":!� <br />