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SERVICERECUESi 9,5,, f o3t� <br /> Type a. Business or Property FACILITY 10 S SEITACE REQUEST: <br /> Residence SR0Q 34- (90 <br /> GVNER I CPSATOR BLUNG PARTY CX <br /> Tony Jockovich Trust <br /> FACUN NAME <br /> SREAOOREss N. I Alpine Rd. <br /> . <br /> 767 N. Alpine"" ov.mee se.e a.e. •ere soeea <br /> Mailing Address Of Cifferent from Site Address) <br /> Tony Jockovich Trust c/o Marie Lopez, Trustee , 8567 O*ford Rd. <br /> CSY Stockton , STATE CA 28 95215 <br /> PHONE'm W. AFNAr LANs UsEAPPI.==N: <br /> (20b 948-2482 I — 1b6 -0-� <br /> PSC14Ei2 ra BCS clsnwr L==N Ccm:.. <br /> -CCNTRAGICKI bT-4vN:ERC-CUEMR <br /> RmOuumi;f SLLM PARTY CI <br /> Jim Thorpe Oil ,"Inc. pay <br /> BUSINESS NAME 120E 368-6175MAiLmAwRiess <br /> � <br /> P.O. Box 357 I FAL0 368-1851 <br /> Clrr Lodi , STATE CA ZY 94241-0357 <br /> BILLING ACXNCWLECGF—MEW: L me unrssgned property or business owner,oprimr or=sioritad agent of same,admcw wge that as vIe andls raja—*speak <br /> N&x H6v.-Sawr:E Ewetc`d@RAL HEALTH Civsim hrAary dmrges assardnM wM in projectora=:%*wii be baled m me or my business as dwelled on dm trm <br /> I aha zYtlfy drat Ibare precared this appr clot and 10:10 wad:b be pedomdone red wi W de'vt ac mance with ad SM CACUR•C WM Cminancs Cades.Stardardt STATE and. <br /> FECEaAL WN& � / <br /> PRCPSTY]au52res CwN0 C CP--.ATwlIMNnG�c7 {/ ❑ Ct1-EaAun4==AGENr Trustee <br /> dAA4.CvlrSal deErucPan.preerdaedwndoe so signs rpuiml rifle j <br /> AUTHORIZATICN TO RELEASE INFORMATION:When apprrmhle,L the owmr oroperator of the Property kxm at the above site address.hereby suthmts the release of I <br /> arry and all resuls.geamaurimt dam wmw armonmenmiftb assessmerd infanratfor m me am.ICALtma C.'urrrY P-im:C HEAL-S'�nca Ew Rclaerrx HEAL-,A CM=N as soon 1 <br /> as rt is araftle and at the mme Yme it is provided to fm of my representative. <br /> d <br /> TYPE OF Soma RC-Cumm: <br /> Tank Removal Permit A � Q <br /> CaMMEVTs: 1 1 a�C v�Q r1 _„a�dLG (.✓�-p t <br /> JUN y <br /> SPH`° °P "EP "DEVs\0N <br /> &�� <br /> P ON)tkNZW- <br /> EN�\P J <br /> iNSPECCR's Swwuiie: CONTRACTCIYs SIGNATu <br /> APPRcm aY. ,'6w DATE (c - q- 3 <br /> Ass GNeT TO: Ear ��U DATE 3 <br /> DawSeMcaCompleted Of alreadyeamplehed): I SErnpsCam C3 4PCc 1 3Q4'": <br /> Fee Amount x(0'7 g�-�S �� Amount P2k �. _ ' Payment Date L 1, <br /> Payment Type Invoica d ecl x j�� Received By- i <br />