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MSERVICE REQUEST EHOO61SR revised 09/04/98 <br /> Type of Business or Property <br /> FACILITY ID# SERVICE REQUEST# (� <br /> Tire Service <br /> BILLING PARTY <br /> OWNER OPERATOR Sally Atkins <br /> FACILITY NAME Franks Tire .Service <br /> S EMarket St <br /> ADDRESS5023 NTyPn <br /> smua <br /> strWNumbr olremon <br /> Mailing Address (If Different from Site Address) <br /> T . Atkins 622 W. Alpine ,CITYSTATE CA LP 95204 <br /> Stockton , <br /> PHONE Al W. APN# LAND USE APPLICATION# <br /> (209464-2778 LOCATION CODE <br /> PHONE#2 �T• SOS DISTRICT <br /> CONTRACTOR I SERVICE REQUESTOR <br /> BILLING PARTY <br /> REQDESTOR ❑ <br /> Jim Thorpe Oil , Inc. <br /> PHONE# EXT' <br /> BUSINESS NAME ( 2Q9 368-6175 <br /> FAX# <br /> MAILING ADDRESS 2 9 3,68-1851 <br /> STATE CA ZIP95241-0357 <br /> CITY <br /> i <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 hourly Charges associated with this project or activity will be billed to <br /> me or my business as identified on this form. <br /> rk to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> 1 also certify that I have prepa appli the wo <br /> Ordinance Codes.Standards, A OF. E 12/3/98 <br /> APPLICANT SIGNATURE: DATE: <br /> TTr�i Contractor <br /> OpERATORIMWAGER Cl Ol}H2 AUOIORUED AGENT L=1 <br /> PROPERtt/BUSINESS OWNER ❑ Title <br /> Il APPIJt:ANT 6 not The Bit-UNG PARTY proofafauflromadon m Sign IS A'QUlred <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 enVironmentallsite assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it IS available and at the same Ume it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> Permit <br /> COMMENTS ❑ SPESWL CONcTnON(S)OF APPROVAL❑ OTHER ❑ <br /> py' = <br /> DEC <br /> sAN.Ii'AUUIN CUUNI"f <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVIfL09 <br /> S RE: DATE: 12/3/98 <br /> INSPECTOR'S SIGNATURE: ',, <br /> ENPUTTEE#: DATE: -;L v -1 <br /> APPROVED BY: �;, �,� <br /> ASSIGNEDTO: \� EMPLOYEE#: GATE: =..L t <br /> f l �.�,E' SERVICE CODE: - PIE' 1 n'� <br /> Date Service Completed (if a(read completed): Ci - 4 <br /> Payment Date <br /> Amount Paid <br /> v <br /> Payment Type <br /> Invoice Chedt# Received By: <br />