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SERVICE REQUEST <br /> Type of Business or Property =FA&j <br /> SERVICE REQUEST# <br /> I Metro Bus Co, 1 3 1 > 00 3,�-7a0 <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> Stockton Metro Transit Dist <br /> FAcIUrTY NAME <br /> Stockton Metro <br /> SITE ADDRESS se7..3i 0 . a^ Channell <br /> TTPa Suis a <br /> Mailing Address (If Different from Site Address) <br /> 817 So. Center St. <br /> Cm STATE ZIP <br /> Stockton CA95206 <br /> PHONE#1 EXT. APN# LNo USEAPPLrATION# <br /> ( 20)9-466-8604 <br /> PHONE#2 ca. BO$DISTRICT ' L—O TION CONE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REOUESTOR BILLING PAM IN <br /> Keith A. Tallia <br /> BUSINESS NAME PHONE# EZT. <br /> Oil Equipment Se <br /> MAILING ADDRESS FAX# <br /> P.0- <br /> CITY <br /> mSan Andreas <br /> STATECA LP <br /> 95249 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authored agent of same,admwAedge 11W all site ardor project specify <br /> Pueuc HEALTH SERVICES ENMONuENTAL HEALTH Omsm hourly charges associated with this project or activity w➢be billed to me or my business as identified on this loon. <br /> I also ceruty that I have prepared this application and that the work to be rfonned will be don ante with all SAN JOAQUIN COtwfY Ordnance Codes,Slandards,STATE ane <br /> FEDERAL laws. <br /> APPucANT SIGNATURE: DATE 1 /28/03 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR MANAGER ❑ OTHER AUn10RRFD AGENT tx Agent- <br /> 1(Ai*t WT is ad go OrimPAmY.prodafaudarmdoa to sign is requkvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release T. <br /> any ana all resu n.geotechnical data andVor envlfonmentaftte asseSSmem information m the SAN JOAQUIN COUNTY PLsuc:HEALTH SaTwas ENveoNAENTAL HEAL^. DrvIsION as socr. <br /> as:t U av---Ian! and at me same time A is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: I <br /> COMMENTS' PAYMENT <br /> Tank Removal RECEIVED <br /> FEB 1 0 2003 <br /> SAN JOAQUIN G'Y WTV <br /> PUBLIC HEALTH SEI <br /> EMARONMENTN IR, _ `I <br /> INSPECTOR'S SIGNA RE: CONTRACTOR'SSIGNATUREYelth A. Tall ' a <br /> APPROVED BY: �— UPLOYCziY. I DATE: b <br /> ASSIGNED TO: EMPLOYEE#: Ir DATE: <br /> i r1 V -- <br /> Date Service Completed (N already completed): T SERv1MCo0e 3(.' PIE: &9q <br /> Fee Amount: pb Amount Paid �� I Payment Date —'.i C) 3 <br /> Payment Type invoice: -- rcheck# g'� C4,j :2l j --� Received By:-7�. J <br /> --- Ss0_7 CS 6 <br />