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Sl�� <br /> SERVICE REQUEST EHOO61SR revised 09/04/98 <br /> Type ofBusiness orProperty Auto Service Cente FAGLITYIDft SERVICE REQUEST <br /> OWNER OPERATOR <br /> Ed Niemann BILLING PARTY <br /> FAcaRY NAME <br /> North Stockton Auto Service <br /> SITE ADDRESS 8709 N, Davis Rd. <br /> aa.e� I oke 9bw Nene roe AVn I <br /> Mailing Address (If Different from Site Address) <br /> CITY Stockton STATE CA <br /> ZIP 95209 <br /> PHONE 91 r r. APN 0 LAND USE APPLICATION 1 <br /> j20P 478-1614 <br /> PHONE 82 BOS DlsTaicr LOCATION CaOE <br /> CONTRACTOR/SERVICE REQUIESTOR <br /> REQUESTOR Jim Thorpe Oil, Inc. BILLING PARTY❑ <br /> BUSINESS NAME PHONED QT• <br /> 1209 368-6175 <br /> MARING ADDRESS FAX 0 - <br /> P.O. Box 357 20 368-1851 <br /> CITY Lodi , STATE CA ZIP 95241-0357 <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 hourty Charges associated with this project or activity will be billed to <br /> me or my business as identified on th' rn. <br /> I also certify that I have prepa th Icatlo t the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards FEDERAL I M <br /> APPLICANT SIGNATURE: DATE <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGFR "CJ OTHERAUTwORMAGFM ] -Contractor <br /> MAPPUCANT IS nol tiro 8VdM wiY.proof of aofhorhedon to sign is required Title . <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 erwironmentaysite assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMStON as soon as d is available and at the same thin R is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> Tank removal permit <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER ❑ <br /> CD <br /> INSPECTOR'S SIGNATURE: 'S IO RE: L <br /> APPROVED sy: EMPLOYEE t. - J DATE r <br /> ASSIGNED T0: E9PLOYEe /, DATE: <br /> �, <br /> Date Service Completed (If air dy ompleted): SERVICE CODE: P I E: 3 C <br /> ount Paid Payment Date ` <br /> Fee Amount: - J - T <br /> Payment Type Invoice I Check 0 Recelved By: <br />