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SERVICE REQUEST <br /> k : r Typs df Buelnesror Property FACILITY ID N SERVICE REQUEST# <br /> efR EIRE STATION 0603l9s �0315� � <br /> 'OPMER I OPeMTOR Baum Pw" <br /> LIBERTY FIRE DISTRICT <br /> PACtUTTNAME LIBERTY FIRE STATION <br /> SRE 111 24124 NH BRUELLA ROAD <br /> ebMeeNr fbMN,nwrr. 7jY 1' <br /> MaRing Address (If Dllysrent from She Address) <br /> CITY STATE ZIP <br /> PHONE 01 nr. APNN UNDUSE AppucAmmN <br /> ( 2073 339 1329 <br /> PHONE#1 m. 505 1315RtiT LocATaxCooe. . , <br /> CONTRACTOR ISERMCEREQUESTOR <br /> REDusrron BILLING Pwm q <br /> JAMES J . HOBLI.TZELL <br /> BUSINE34*J1E PHONE N <br /> JAMES J . HOBLITZELL 2 Op 943 7793 <br /> ,'hMq,RNI ADW311 FAx N <br /> BOX 30331 1 943 2811 <br /> Crrr 'STOCKTON STATE CA IJP 95213 <br /> i I OW E&SiEmEtfl'I, the undeni0ed property or buslness avmer,operator Or authorized agent of same, acknowledge that UI 39e F(Wor prplect:sped k <br /> Po"HEALTH s EMMONUEMA1 HMTH DrvowN howdy charges wodated wM m4 prop or aodrhy unit be blhed m me or my business as Idend4d owl this t01fll,;, <br /> slsp dray 1hai I have prepared m appllcatlon and that me wank to be performed wig be done in taoommnce Wm ag 3u+JOAOUIN COUNTY OrdMena Codeal Scdit"$wx am <br /> Ji1aUC,Wf rIONANRE: '��� DATE: /d•-��DZ .. <br /> IRE 6111ESTAN S FERT FIRE CHIEF <br /> PIk1 TY(EVIINESe ONNEA , pvtATORI OTHu Aurw4u ED AOFM <br /> NAPftrwrerdma BE= rywrofwNarkeden ro,lpn6nquaed `i ties <br /> AUTNCRILITION TO RELgISE INFORMAi1021:When applicable,I,the ovmer or operator of the property)casted at the above she address,hereby euth ft Wwral"eq O <br /> any and M results,gwIechnial data andfor environment0site wssament Information b the SAN JOAOWI CDulm Punic HMTN SERVICES 11"ONNIENTAI HERM by"'47.10o1 <br /> as N fes w1floblo and at the aims Ihne R M pmvided to me or my repreaa>naft <br /> TrPporSoautefuauerrro: REMOVAL OF TWO (2) UNDERGROUND FUEL STORAGE TANKS <br /> ' GOMM1NriT <br /> PAYIVIEN i <br /> RECEIVED <br /> v SAN JOAOUIN COUNTY <br /> PUBLI HEAUHHRAEniONI'll <br /> ' . <br /> RON <br /> .. 'INSPECT R'r 010 ATURE: CO OR'e SIONATORE: <br /> *FRrnl DBD ( EstPtaiott. 3 Sp�� <br /> AMa MTO: 'Y I r�yTl _�� BlhtgYU* �JO a... DATE: 'I U <br /> Y.:.y <br /> 'Doti Ser4lcsCompleted (Hslnedywmpleted): .." SPxvcECoDE ' .( , "PI�t <br /> Amoupt Pew Payment Dstr 7 0/ v <br /> Hi AmaphL 5L2 D v a <br /> PeymeMType Ilitiolw# Chedt# Redelved ty' <br />