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SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BILLING PARTY ❑ <br />SERVICE REQUEST # <br />Vaccant lot <br />1 <br />BUSINESS NAME <br />5 (,oaa 3e) <br />OWNER OPERATOR �. LL <br />BILLING PARTY <br />Souza <br />- <br />FACILITY NAME N / A <br />368-6175 <br />SITE ADDRESS <br />FAX# <br />P.O. Box 357 <br />Slow NUMr <br />9Y(eBon <br />1 "" <br />7Ynlsn�� <br />ZIP 95241-0357 <br />SuNi <br />Mailing Address If Different from Site Address) <br />ES <br />ENVIRONIMENTAI Ili"F ill <br />105 E. Tenth St. <br />CITY Tracy, <br />STATE CA ZIP 95376 <br />PHONE#1 <br />APN# <br />.. 1, <br />LAND USE APPLICATION <br />V09) 835-8330 <br />CONTRACTOR'S SIGNATURE: <br />PHONE #2 <br />BOS DISTRICT <br />LOCATION CODE. <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR <br />.Underground <br />BILLING PARTY ❑ <br />Jim Thorpe Oil, Inc. <br />BUSINESS NAME <br />ED <br />PHONE# <br />�T <br />- <br />20 <br />368-6175 <br />MAILING ADDRESS <br />FAX# <br />P.O. Box 357 <br />20 <br />368-1851 <br />CITY Lodi, <br />STATE CA <br />ZIP 95241-0357 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acinordedge that ad site andlor Project specific <br />PUBLIC HEALTH SERVICES EwRoNMENTAL HEALTH OhnsioN hourly charges associated with this project or activity will be billed to ma or my business as identified on this form. <br />1 also certify that I have prepared this <br />FEDERAL laws. _ <br />APPLICANT <br />PROPERTY/ <br />done in accordance with at SAN JOAOUIN COUNTY Ordinance Codes, Standards. STATE and <br />WiAANAGER Z OMAUnwRDED AGENT ❑ <br />NAPPjaWis nor ae 6LU%ZP.VnY. yroo/ol+udmrlridar ro sign it nW6d <br />5/29/01 <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable. I, the owner x operator of the property, located at the above site address, hereby authoras the release of <br />any and all results, geotechnical data andlbr emlronmentaitsite assessment infortnation t0 the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENJIRONMExTA1 HEALTH OmsION as Soon <br />as d is available and at the same fire it's provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />.Underground <br />Tank Removal Permit <br />-AYIV1 <br />ED <br />COMMENTS: <br />- <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERIA N <br />ES <br />ENVIRONIMENTAI Ili"F ill <br />. i3ln�, <br />.. 1, <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY: <br />JJJ <br />EmpL0Y`.EA: <br />DATE: 5/29 01 <br />ASSIGNED To: <br />�IO� <br />EMPLOYEE 9: '�1�X4 <br />DATE: <br />Date Service Competed (if al <br />completed): <br />SERv10ECODE: <br />PIE: c/," <br />Fee Amount <br />Amount PaidZ C, <br />Payment Date tl <br />Payment Type <br />Invoice # <br />Check 9 <br />1 Received BY: <br />