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SERVICE REQUEST <br /> Type of business or Property FACILITY ID# SERVICE REQUEST# <br /> Municipality <br /> OWNER I OPERATOR BLLM PARTY I$ <br /> The City of Stockton <br /> FAcaun NAME <br /> The old Chase Cheyr9let Building <br /> SITE ADORES <br /> sFiunter <br /> Mailing Address (If Different from Site Address) <br /> 305 N. E1 Dorado St . , Suite 200 <br /> Cm Stockton, STATE CA ZIP 95202 <br /> PNoNE#I APN# LAND UsEAPPucATaN# <br /> 209 937-8320 <br /> PHONE 92 trc BOS DISTRICT - LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR BLyNd;PARTY❑ <br /> Jim Thorpe Oil , Inc. <br /> BUSINESS NAME PHM# ea <br /> The City of Stockton 1 (2039 368-6175 <br /> MAILING ADDRESS 1 FAX# <br /> P.O. box 357 2 368-1851 <br /> CITY Lodi, STATE CA LP 95241-0357 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site ardor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourty charges associated with the project or activity win be billed to me or my business as identfied on this farm. <br /> I also cardfy that I have prepa is appf lion that the be perfomhad will be done in accordance with all SAN JCAcuN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL IBM. <br /> APPLICANT SIGNATURE: DATE: /Ado <br /> v I <br /> PROPERTY/BUSINESS OWNER C OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If App is;nor dMBwloPwrn.prod ofwtlpriadw bsign is"hVid Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorma the release of <br /> any and all results,geotechnical data ar Vor anvironmentallsile assessment information to the SAN JOAOUN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION as soon <br /> as it is available and at the same time it is provided to me or my reprasentedve. PAY NA.L I V i <br /> TYPE OF SERVICE REQUESTED: <br /> Tank Removal ,Permit <br /> COMMENTS: - - - <br /> APR t A ?05j <br /> SAN JAQUIN UQ PUBLIC HEALTH ER\ACFTM <br /> � NVIRONMENTAL HEALTH PIN,` <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: \ EMPLOY�fh. UO(:D l DATE: ` Q <br /> ASSIGNED TO: \ �.�� EMPLOYEE#: DATE: <br /> Date Service Completed (If ahssdy completed): SOMMCODE: U 'PIE:. <br /> Fee Amount: 5��, �'` Amount Paid Payment Date <br /> Payment Type - Invoice# Check If Received By: <br />