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' SERVTCE RECUEST <br /> Type of Business or Property FACILITY 10 1 SERVICE RECUEST <br /> Newspaper W 3 S S X3 4 <br /> BUNG PARrit <br /> CvmER I OPERATOR The Record, Stockton Newspapers , Inc. <br /> FACZITYNAME The Stockton Record <br /> SITE MORESS 530 E. Marl <br /> sw"Nubr I <br /> Mailing Address (if Different from Site Address) P.O. Box 900 <br /> CTY Stockton , CA 95201 STATE ZIP <br /> P4ONE*1 (209)832-8642 °c APN LANOUSE APPUCATION <br /> t <br /> PHONE#2 �• BOSDISTRICT LOCATIC COM <br /> CONTRACTOR 1 SERVICE RECUESTOR <br /> 3111AiG PARTY a <br /> REGUESTOR <br /> Jim Thorpe Oil , Inc. <br /> BUSINESS NAME I PHONE 4 Exr <br /> 09 368-6175 <br /> MAwNGAOPRW. Box 357 F09 368-1851 <br /> Cn Lodi . CA 95241-0357 STATE ZIP <br /> BILLING ACKNCWLEDGEMENT: G the undersigned Property or business owner,operator or authorized agent of same, acIatowledge that ad safe andlor Prole,specix <br /> PUarx HEAL H ScRVtCPS EyvrRcrarErrrAl.I-j&Li H OMSION hourly charges associated` M Me plea Or��Y+W be baled to me or my business as idertc6ed on thm t, = <br /> I also certify that I have prepared this lic wen and that the weds to be perfomred wi dare in acrdance with ad SM 'CAauN CcuNrr Ordfner=Codes,Standards.STATE and <br /> F�ERAI.!awe. J <br /> APPUCANT SIGNATURE: <br /> °ate �a - _- 2 <br /> PRCPSERTYI BUSINESS CMFR CPERATORI MANAGE QrHERAUTHCRam AGENT true <br /> $APR-Currsnorm.$ccaicP,ary vWc(ar,a,o►=dontosWismW*d <br /> AUTHORIZATICN TO RELEASE INFORMATION:When applicable,L the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and ad results,geotechmcal data arxUor emrironmsntatlsb assessment information to the SAN JOAOUN COUNTY PUauc HEALTH SEWMS EW RONme+TAL HEALTH DNmxN as soon <br /> as it is available and at the same 5me it is provided to me or ny representasiv& <br /> TYPE OFSamc-r-REQUESTM: Underground tank removal Permit <br /> c�wtE <br /> RECEIVED <br /> OEC 1 <br /> SAN JOAQUIN COUNTY <br /> PlIBLIC HEALTH SERVICES <br /> NVIROINMENAL HEl'•.i TH DIVISION <br /> INSPECTOR'S SIGNATURE Yom, CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: C1 lA �� LIO�L Esi�^Yw : Z 1 -� 'ATE: 12/9 2/n 2 12 -LG C t <br /> E�IP��YE 3'r� DATE: <br /> ASSIGNED TO: 3 <br /> Date Service Completed (if already comp) d� SES Cc (�` 3 P I c: <br /> Fee Amount Z Ip ` Amount Paid 1 "�, I Payment Date <br /> Rec_ived <br /> Payment Type ;' Invoice. I Check �, I By <br />