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' L SERVICE REQUEST ' <br /> Type of Business or PropertyFACILITY ID 4 SERVICE REQUEST# Q <br /> Mosquito Control Corp. Yard E6 0d (� �j'�07, -7I I <br /> OWNER OPERATOR BILLING PARTY❑ <br /> San Joaquin County Mosquito & Vector Control District <br /> FAct.TTYNANE Mosquito Control Corp. Yard <br /> SITEAaOREss 200 N. Beckman mRdr . TYw soad <br /> stew xww. or�me <br /> Mailing Address (if Different from Site Address) 7759 S. Airport Way <br /> CITY STATE ZIP <br /> Stockton, CA 95206 <br /> PHONE41 Ekv APNS LANA USE APP=TIGN$ <br /> (20? 982-4675 <br /> Far. BOB DISTRICT --= LOQAT10NCam <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BauaG PARTY <br /> Jim Thorpe Oil, Inc. <br /> BUSINESSNANE Jim Thorpe Oil, Inc. PRONE;; aT• <br /> 0 368-6175 <br /> MAILING AwREss FAX# <br /> P.O. Box 357 Q09 368-1851 <br /> CITY Lodi , STATE CA ZIP 95241-0357 <br /> BILLING ACKNOWLEDGEMENT: 1,the undersigned property or business owner,operator or authorized agent of same, admamedge that all site and/or Pmled spedfs <br /> Pi HEALTH Sc.RVlas EwiRcNiwENTAL HEALTH DIVISION hourty charges assodated with this project or activity YAt be bided to me or my business as'deni on this bmt_ <br /> I also entity that I have prepared this application and that the wart need wil be done in accordance with at$AN.IaAaUW COUNTY Ordnance Codes,Standards,STATE and <br /> FEDEPALIaWS. _h <br /> APPUCANTSIGHATURE: X GATE �� L <br /> PROPERTY/BUSINESS ❑ OPERATOR/MANnGER ❑ OTHERAUTKPR AGENT Y,] Con acto <br /> tlAPru:wfiSnaflhaB�r.Ararv.yraala/wdromdwtosignunquesd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the awneror operator of Ne property bated at the above site address.hereby authorize the release of <br /> any and all muds,geotechmial data and/or emmmnmentapsite assessment information m the SAN JoAci CcuNTy PUeuG HEALTH SEWK;ES EWIRCNME74TAL HEALTH OIVSICN as soon <br /> as it is available and at the same time rt a provided to me or my representative <br /> TYPE OF SERVICE REQUESTED: Underground Tank Removal Permit <br /> COMMENTS: F5AYMENI <br /> RECEIVED <br /> PUBLAQiN COUNTY <br /> IC HEALTH SERVE <br /> ENVIRONMENTAL HEALTH DIV19C'J <br /> INSPECTOR'S SIGNATURE: ��Q CONTRACTOR'S SIGNATURE: <br /> APPROVED NY: ✓tl���-/�,� FEtPLO-YEEt ) r 7� A <br /> AmmEo To: 64-e-, r-6 - e ENetarr E# `7 S 8 a D <br /> Date Service Completed (if already completed): SERvICECOCE: .C-Ir 3 PIE,- <br /> Fee Amount Amount Paid Paymertt Date I I / cA 0 <br /> Checkil �" ReemedBy <br /> Payment Type � Invaicex 7 I ; <br />