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SERVICE REQUEST .e/ EH0061SIR revised 09/04/98 <br /> Type of Business or Property Residence FACILITY ID SERVICER ST# <br /> OWNER OPERATOR L.R. Varwig NN BILLING PARTY <br /> FAcILRY NAME Same as above <br /> SnEADDRESS 16500 E. Brandt Rd. Lodi , CA <br /> S NemEr ehgnn SIIWt Na. Tree Suiter <br /> Mailing Address (If Ditferentfrom SbAddress) P.0. Box 99320 <br /> CITY Stockton, STATE CA ZP 95209 <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> 0 993-6110 <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REWESTOR BILLING PARTY❑ <br /> L.R Varwi <br /> BUSINESS NAME �9 <br /> Jim Thorpe Oil, Inc. P 368=6175 <br /> MaUNG ADDRE5Y5 FAX <br /> .O. Box 357 ?091368-1851 <br /> CITY Lodi, 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 DIVISION hoUdy 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 prepared this applicanba work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards,STATE and F g ,� <br /> APPLICANT SIGNATURE: / DATE: I Gf�Q Z <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER - OTHER AuTHORQED AGENT ❑ <br /> 1APRUCANTlsratMe BILUNGPARTV Pfoofofauthorization 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 environmentaUsae 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: Underground tank removal permit <br /> COMMENTS ❑ SPECIAL COWMN(S)OF APPROVAL C1 ODER <br /> \��lV c COON s <br /> 5 11, <br /> ONMEC1iF`�NEP�StfC� <br /> INSPECTORS SIGNATURE: C l NATURE: DATE 11/16/02 <br /> APPROVED or EMPLOY #: DATE: _ <br /> ASSIGNED TO: 5 1KOYE#: DATE: <br /> Date Service Completed (if already completed): � SERVICE CODE: P i E: D <br /> Fee Amount: AmountPaid �o�-u CJ Payment Date / p t. <br /> Payment Type Invoice 9 —cheat y{7 0 Receked By. <br />