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SERVICE REQUEST (EH DO 61) Revised 8/23/93 <br />OWNER/OPERATOR <br />DBA <br />ADDRESS <br />5000 S. Airport Way <br />P <br />I.TAI <br />Stockton, STATE CA ZIP 95206 SET °A' ---- <br />CITY E,A Lgg.. STATE.ETA G` ENR"�"GS <br />APP IF {tend Use Application e — ,�.w oeoucTi.. .�nND AETA4N <br />I [B <br />Lea I Iweaelal GOCa I <br />CONTRACTOR and/or <br />SERVICE REOUESTOR Jim' Thorpe Oil, Inc. BILLING PARTY Y / N <br />s <br />DBA <br />MAILING ADDRESS P.O. BOX 357 <br />Lodi, <br />CITY <br />I <br />PHONE Al (209 368 6175 <br />1 - <br />FAX I ( 209 )__368 : 1851 <br />STATE CA ZIP 95241-0357 <br />BILLING ACKNOWLEDGEMENT- I, the undersigned owner, operator or agent of some, acknowledge that all site and/or protect specific <br />PIIS/EIIG hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br />Page 1 of this form. <br />1 also certify that I have prepared this application and that the work to be performed will be dons IORAYMENZaccordance ith ell SAN <br />Jd10UIN COUNTY Ordinance Codes soVtszdard"� Aederel laws. RECEW-ED <br />APPLICANT'S SIGNATURE s MAT 4 ( ,IJ.70- ..,. <br />4/27/98 ''`' <br />Contrac or Date: <br />title: SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SLrAE - of <br />AUTHORIZATION TO RELEASE INFORMATION!. in addition to the above, when applicable, I, the owner�tapagaAllEYJ4RLRI .rfFPISIVTSYo <br />the property located at the above site address hereby authorize the release of any and ell results, geotechnic8i'dats and/or <br />Ir <br />environmental/site sssessment informotlon to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION at soon at <br />It Is available and at the Same that It is provided to at or try representative. <br />0< 0 AA t 'l Service Code <br />Nature of Service Reque$ I CQ..A( t <br />to LULL VL, Employee <br />IFACILITY ID / <br />I � <br />RECORD ID N <br />CJI <br />^ <br />r� <br />Stockton Metropolitan Airport <br />FACILITY NAME <br />SITE ADDRESS <br />5000 S Airport Way <br />- <br />]aR <br />ell, <br />Stockton. <br />CA ZIP 9:5206 <br />- <br />San Joaqin County, Departrnent <br />of Aviation <br />r _4o <br />OWNER/OPERATOR <br />DBA <br />ADDRESS <br />5000 S. Airport Way <br />P <br />I.TAI <br />Stockton, STATE CA ZIP 95206 SET °A' ---- <br />CITY E,A Lgg.. STATE.ETA G` ENR"�"GS <br />APP IF {tend Use Application e — ,�.w oeoucTi.. .�nND AETA4N <br />I [B <br />Lea I Iweaelal GOCa I <br />CONTRACTOR and/or <br />SERVICE REOUESTOR Jim' Thorpe Oil, Inc. BILLING PARTY Y / N <br />s <br />DBA <br />MAILING ADDRESS P.O. BOX 357 <br />Lodi, <br />CITY <br />I <br />PHONE Al (209 368 6175 <br />1 - <br />FAX I ( 209 )__368 : 1851 <br />STATE CA ZIP 95241-0357 <br />BILLING ACKNOWLEDGEMENT- I, the undersigned owner, operator or agent of some, acknowledge that all site and/or protect specific <br />PIIS/EIIG hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br />Page 1 of this form. <br />1 also certify that I have prepared this application and that the work to be performed will be dons IORAYMENZaccordance ith ell SAN <br />Jd10UIN COUNTY Ordinance Codes soVtszdard"� Aederel laws. RECEW-ED <br />APPLICANT'S SIGNATURE s MAT 4 ( ,IJ.70- ..,. <br />4/27/98 ''`' <br />Contrac or Date: <br />title: SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SLrAE - of <br />AUTHORIZATION TO RELEASE INFORMATION!. in addition to the above, when applicable, I, the owner�tapagaAllEYJ4RLRI .rfFPISIVTSYo <br />the property located at the above site address hereby authorize the release of any and ell results, geotechnic8i'dats and/or <br />Ir <br />environmental/site sssessment informotlon to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION at soon at <br />It Is available and at the Same that It is provided to at or try representative. <br />0< 0 AA t 'l Service Code <br />Nature of Service Reque$ I CQ..A( t <br />to LULL VL, Employee <br />/ 31-13 <br />Data <br />Assigned <br />^ <br />r� <br />I Date Service Completed —/—/— Further PROGRAM ELEMENT <br />irer Action Required: Y / N I <br />