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SERVICE REQUEST <br /> Type of susinesa or Property I FACILITY ID# SERVICE REQUEST$ <br /> OMERI OPERATOR <br /> The City of Stockton BwAtG PARrr <br /> FACLV NAME City Property <br /> SrrAnoRESS E. I Fremont St . <br /> 428 sms <br /> srr..sw. a." se.e nen. I tYe. <br /> Mailing Address (if Cifferent from Sita Address, <br /> 445 N. Eldorado St . <br /> Cr Stockton, STATE CA LP 95202-1997 <br /> P40ME <br /> W. APN3 - =LANW0UsVeAFPL=TCN4 <br /> ( (209) 937-8358 <br /> c <br /> PHONE 12Err BOS G1:irAC =NCO <br /> LE _ <br /> --- -- --_—-CCNTRACTcx/a�cavncc�-0t1ESi0R - <br /> REGuESTOR - pe nr_PARr f Q <br /> Jim Thorpe. 0i1 , Inc- <br /> BMW=NAME <br /> nc.BMW=NAME I PHONES <br /> 1(209) 368-6175 <br /> MAwxGAmREss I FAX (209) 368-1851 <br /> P.O. Box 357 f <br /> Cr Lodi, STATE CA ZIP 95241-0357 <br /> BILLING ACXNCWLEOGEi1E?!i: L the W&emgnW preop'/or busmen amer,OWZW or anhorasd ag*M If same'acme lenge 1=a1 MIS Mwor XW=4:6G <br /> Puma HEAUH SERVICES Ewwcw,erru;iEKrH CAtVcx homy chases mocz ed wtlls Ste pmjeecr XQ't wd be bled m me ar my business as eery an me bra. <br /> I area oavfy fat I have pmaared th oat to,mark b oe periortred wi be dCM n a=WCO with ad GAN.CAarw Caum Cmkience Codes,Sfarsdadt STAT-,and <br /> AARUcwr SMATUAE: <br /> PROPERTY/SUSWEWCWNER C CPERATOR/MWAMMM-R Q OtHERAunaRmAGWV9 C.IK <br /> dAar�cwrisnaaaBrucFan.podofavtlsmdon mspnunquiv0 Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When appfrable.t Sne avreer ar apeotor of dna property loafed a die above sib address.lmebY autham Sne release of <br /> any and at mMuft geateamal dao&-Alar SITAM rrmeYsib assess WM infmnwbn m ab SAx;r n mr cwm ftLc HPN.iH Sa.yo=s Ewpmwe AL HFx-,s ON=N as soar <br /> as t is available aM at the same Sme i s pravtled to me or my mwessambve. <br /> TyPEGFS0"r--REcuES1W: Underground Fuel Storage Tank Removal Permit ( /a -� <br /> COMMENT&: PAYMENT <br /> RECEIVED <br /> AUG 15 2003 <br /> SAN JOAQUIN COUNTY n <br /> PUBLIC HEALTH SERVICES <br /> 1 <br /> ENVIRONMENTAL HEALTH DNtS10N <br /> INSPECTOR'S SIGNATURE CCNTRACMR'S SIGRAN <br /> APPRGvm sy: W E ^y=t. P, 1�,j GATE 8/12/0 3 <br /> AswNm To: 5 CA I EWL0y=x. 3 CAM <br /> Date Service Completed (ff afreedy completed): I SazvtcCeee 0 L'. P I'e- <br /> Fse Amount 7 o(J Amount Paid r Payment Date <br /> Payment Type L. Invoice 9 I Check S .J ` Received BY- <br />