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SERVICE REQUEST .ur► __ <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> Metro Bus Co. <br /> BILLING Parra❑ <br /> OWNER OPERATOR <br /> Stockton Metro Transit Dist- <br /> FACILITY NAME <br /> Stockton Me <br /> SITEADDRESS 730 E. Channell <br /> $I N.w. 004 su..rx.m. irw sme.a <br /> u <br /> Mailing Address (If Different from Site Address) <br /> 817 So. Center St. <br /> Cm STATE ZIP <br /> Stockton95206 <br /> APN#PHONE#1 APPLICATIONLAND UsE <br /> ( 20)9-466-8604 <br /> PHONE#2 am BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> BILLING Pum 0( <br /> REDUESTOR <br /> Keith A. Tallia <br /> BUSINESS NAME PRONE# <br /> Oil Equipment S <br /> 202 <br /> MAILING ADDRESS F0.Y# <br /> Cm P 'ACA ZIP 95249 <br /> San Andreas <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorised agent of same,adwowledge that as site and/or pmfect specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH UNism hourly Charges associated with this project or activity wfil be billed to me army business as identified on this form. <br /> 1 also cerofy that I have prepared this application and that the work to be perfanned wig be don rdance with all SAN JOAAuw COUNrc omenance Codes,Standards•STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE. 1 /28/03 <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR MANAGER ❑ OOffRAuTmoRiZEDAGENi CX ..`AaPnt <br /> aavPhhrly%is north,84,wpu ,p vdefwMariatlon to s%w is requkvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When apprable,I.the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all mutts,geotechnical data and/or envimnmentalste assessmem kdarmatan to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EiMRONMENrAL HEALTH DivsAN as sour. <br /> as I is available and at the Same time it is provided to me or my representafift <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> Tank Removal <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'SSIGNATUREKeith A. Tallia <br /> APPROVED BY: Est rLDY—m#: DATE-' _. <br /> ASSIGNEDTO: EMPLOYEE#: DATE: <br /> Date Service Completed Cd already completed): - SER ICECODE: - _ PIE: _-----. <br /> Fee Amount Amount Paid I Payment Date <br /> Payment Type Invoice# Check# Received By: <br />