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SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# <br /> Commercial SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> James King Trust LO 33 yb Z KIM P <br /> FAcutt NAME <br /> James King Trust Property <br /> SITE AOoREss <br /> 541 m.esum. E p m, Harding Way vo. Sm s <br /> Mailing Address (If Different from Site Address) <br /> James King Trust C/O James W. Love , Trustee , 4545 Georgetown Pl . , Bldg. D <br /> C TY STATE ZB' <br /> Stockton , CA 95207 <br /> PHONE#t W. APN# pLANOUSEAPPucATfoN# <br /> (Loi 951-5001 27 -1S� 3J <br /> PHONE#2 0cr. SOS OISTRC, - LOCATION COGS- <br /> CONTRA:I OR i slctvrCE REQUESrOR --- <br /> REOUEsTOR Bur.mG PARTY❑ <br /> Jim Thorpe Oil , Inc. <br /> BUSINESS NAME <br /> PfLa 0 368-6175 �c <br /> MAumc Awitess <br /> P.O. Box 357 IFV 368-1851 <br /> CITY Lodi , CA 95241-0357 STATE ZIP <br /> BILLING ACXNCWLECGE.itENT: 1,one unde sgned pmputy or business awner,operator or authorized agent of same, aedmowiedge Cut ad sfte motor 7rWec scecft <br /> PUBLIC HEALTH SERVICES EWRCta@RAL HEALTH CNIsm houny dnames asSotted vim MRs pmFYterr acyvify va he billed to me or my business as idenlf d on tm`Afro. <br /> I also mr*that I have Prepared tho appkadon and that re weds t be pedanned WA bre done''a=Xdance with ad SAN:QAaJR CCUNry OtcTnance Codes,Standards.STATE and <br /> F--EkAL!Mvs. <br /> T <br /> AP <br /> PUWn'sw,utTURE: PATE <br /> PRCPERTYI BusiNESS ❑ OPMATORIMANAGERi Q OrRmAUheCR®AGENT Trustee <br /> YAPrtcwre;nddaea MP_r Poddauelarmdm to spec nmr*d rift* <br /> AUTHORIZATION TO RELEASE INFORMATION:When appifable,L the owner or of I of the property located at die atwve sits address,hereby autharrm ore Idessse of <br /> airy and ad resu t,geotedmicil data arA!!or emimn flsme assessment infonrwlorr to die SAN.IOAOUIN CCUNTY PU11"HEALTH SEWICES EYVIRCtYE.HTAI HEAD OIV=N as soon <br /> as a is available and at the same Hme it is provided to me or my represenrative. <br /> TYPE OF$amcEREOuEsm: Underground Tank Removal Permit <br /> COMMEWS: PAYMENT <br /> RECEIVED <br /> APR — 8 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENV ONMENTAL HEALT DIVISION <br /> INSPECTOR'S SIGNATURE: WNTRAOTOR'S SIGNATURE: 71, <br /> APPROVED BY: E'JR.OYP�a: / /� OAT=•4/S/O 3 I <br /> ASSIGNED TO: EmpLOYEE t, Y DATE: <br /> Date Semite Completed (if already completed): J I Saw=COCE: 63q 1 P 1 c <br /> Fee Amount '70� I Amount Paid ' I Payment Date �/� /L, <br /> R( <br /> i Payment Type L Invoice A I Check X - <br /> Received By: <br /> ed C <br />