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PAYMENT <br /> SERVICE REQUEST AUG 2 0 19%00 61) Revised 8/23/93 <br /> FACILITY IgRECORD 10 M [[ `IILVOlDAJ FOUNTY <br /> A � Y f'7 �. 91-Ir p:r i c <br /> =77ENTAL HEALTH DIVI81 <br /> Cal Tank Line, Inc . BILLING PARTY Y- / H <br /> FACILITY NAME <br /> 3105 S. El Dorado St . <br /> SITE ADDRESS <br /> Stockton, CA DA ZIP 95206 <br /> CITY <br /> J Cal Tank Lines, Inc. gIIUNG PARTY Y / x <br /> OWNER/OPERATOR <br /> PHONE N1 ( 209 > 466-3554 <br /> DBA <br /> P.O. Box 6245 PHONE 02 ( > <br /> ADDRESS <br /> CITY Stockton, STATE CA zip 95206 <br /> —APN M Lend Use Application N — <br /> BOS Dist <br /> E Location Code <br /> --- <br /> CONTRACTOR and/or Jim Thorpe Oil , Inc . BILLING PARTY Y / N <br /> SERVICE REOUESTOR <br /> PHONE N1 (209 ) 368 _ 6175 <br /> DBA <br /> P.O. Box 357 FAX IF C 20 ) 368 : 1851 <br /> MAILING ADDRESS <br /> Lodi, STATE CA ZIP 95241-0357 <br /> CITY <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> pHs/EHD 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 1 have prepared this appll .and t at the work to be performed will be done in accordance with ell SAN <br /> JOA0UIN COUNTY Ordirvirtee Codes S sr , Statederail laws. PAYME k_ <br /> APPLICANT'S SIGNATURE AUG if 1998 <br /> 1 <br /> Contractor Date: 8/17/98 N tJJV <br /> Title: ppSANJ,O�IAQL W e!U.N iY <br /> NBM10F7AAENT '�6ESseme, of <br /> AUTHORIZATION To RELEASE INFORMATION: In addition to [he above, when applicable, 1,. the owners, TA ,,,:.; - VJs <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical r4� bad/or <br /> environaental/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is avaitabte and at the same time It is provided to w or my representative. <br /> ''1 �/Iul - s Service Code <br /> Nature of Service Request: a' �Jw <br /> (eyes N Date <br /> Assigned to <br /> �Jl T( 'Tl, :/rGID,� ErtPH <br /> (/Y� PROGRAM ELEMENT 7�.M1. <br /> Date Service Carpleted _/ / Farther Action Required: CY / <br /> Receipt N Check N Recvd By <br /> Fee AnKKmt <br /> Amount Paid Date of Payment Payment Type . <br /> �, � A- 1,16 4p <br /> UNIT CLK _./--/— <br /> _._.. ACCT=r <br />