Laserfiche WebLink
SaVTCE RECUEST <br />Type of Business or Property • <br />Butn+C PARTY I <br />FACUN 10 <br />SEWCE REQUEST S <br />Card Lock Facility <br />209 368-6175 <br />ot( <br />F1� 368-1851 <br />CwNEz1CPetATOR Owner - Jim Thorpe <br />Oil, Inc. <br />BII.LNGPARty0 <br />Operator - Van De <br />Pol Enterprises <br />FAcL,Ty NAME Lodi Pacific Pride <br />Card Lock <br />SIZE Acoms <br />SPN JOPO 0tNAVIC �SS10N <br />D <br />351 <br />o <br />Beckman,,,a <br />Mailing Address (if Different from Site Address) <br />E�1p,ONMEN�k'- <br />P.O. <br />Box 357 <br />Jim <br />C'rr Lodi, <br />MPC-r.CR'S SIGNATURE— <br />STATE CA ZUX 95241-0357 <br />P. 368-6175 <br />���}� <br />APN <br />Lura UsEAPPt_'CATION <br />Pt�NE #Z ELT.BCS <br />OXTR C' <br />LDCA=N Cac_E. <br />. - ---- COHTAACCRISc�itCERL-CtJESTOR __ _ <br />REaua mR <br />Butn+C PARTY I <br />Jim Thorpe Oil, Inc. <br />pAYJ\A <br />BUStNEasNAflE Same as above <br />209 368-6175 <br />MAa:NGAwRm P.O. Box 357 <br />F1� 368-1851 <br />Cr Lodi, <br />STATE CA Z:P 95241-0357 <br />BILLING ACXNCWLELGF-MENT: 4 the wVmz4ned property or business owner, opu=r or aut crzed agent of same. admcwledge 1= ad sde andtcr project speaft <br />Pu8LC HEAIT H SERVICES &WCN Ae4TAI HEAD CI sim hourly dmrres assocated watt this project or acVdy ,#a be Wed ie me or my business as fdenatied on dta tam <br />I also mrify stat 1 have precared this appfic den and that the wmt to be dcaned wd be dcoe in a==dance wM ad Sm cAcu24 C: uxry Crdnance Codes, Sundards. STATc and <br />FEEaaLlaws. Jim Thor , c <br />AP?LGwr SiGNAiURE: <br />PRCPC-qIY/ BUSINESS GWNE4 <br />CPSATCR/MANAGER a Q CrAERAUTNCRI`7AGcrr C <br />D1APR-rwrsnor1s8tr rePurn. arodof wdx riadoa wap is mqursd rifle <br />AUTHCRQATICN TO REI -EASE INFORMATICN: 'Nhen applicable. I. Atte owner or operdmr of *rte property crated at the above site address. hereby audtaas the release cf <br />arty and ad results. ^yeete=nical data and/or am=nrnenmUsite assessnern m*=nadcn to the SMCAG'Utri C,12M PUst:C !4E&-, i SccvtC`'a E,,WCN&ERx HEALTH ONM;CN as sccn <br />as Us available and at the Mme !mw it's provided to me or my represent ive. <br />TYPEGFScRY1CcRECiJESTID: Line and <br />tank retrofit Permit <br />pAYJ\A <br />rajwE.rrs: <br />,� 3 2Q03 <br />� E8 <br />�p�NN <br />SPN JOPO 0tNAVIC �SS10N <br />D <br />• <br />HEAtjN <br />E�1p,ONMEN�k'- <br />Jim <br />Thorpe Oil, Inc. <br />MPC-r.CR'S SIGNATURE— <br />C.-mmAcmWs SIGNATURE by <br />APPW40 8y: <br />Esus .^Y:E 3: <br />OAT-- <br />ASSIGNED M:��YE-- <br />(CATI~ <br />02M S&vica Completed (ff already campletedj: <br />Saw=- C:.CE: <br />Fee amount <br />' Amount Paid �� _ <br />' Payment Date <br />Payment TypeI Invoice I <br />I Check <br />Recalved By j <br />