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SERVICE REQUEST EHOO61SR revised 09/04/98 <br /> Type of Business or Property FACILITY ID# SERVICE REOUT# <br /> Storage Yard <br /> OWNER I OPERATOR BILLING PARTY <br /> Joe Omachi <br /> FACILITY NAME <br /> SITE ADDRESS 35 E. Jack o 1p ,y�,t • <br /> Str Num w enal,e <br /> Mailing Address (If Different from Site Address) 1105 W. E1 Monte <br /> Cm Stockton , STATE CA ZIP95207 <br /> P <br /> HO <br /> N <br /> E <br /> #1 Ur. APN# LAND USE APPLICATION <br /> 20 477-8070 <br /> PHONE 92 trr. BOB DRT TCT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REOUESTOR BILLING PARTY❑ <br /> Jim Thorpe Oil Inc . <br /> BUSINESS NAME PHONES Err. <br /> 1209 368-6175 <br /> MA"G ADDRESS FAX 0 <br /> P.O. Box 357 (209 368-1 1 <br /> CITY Lodi, STATE CA ZIP95241-0357 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same,.acknowledge that all site <br /> and/or project specific PUSUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be belled to <br /> me or my business as identified on this form. <br /> I also certify that I have prepared INS pplicad tha le work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards,ST TE a d FED L laws 6/5/00 <br /> APPLICANT SIGNATURE: c DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPEPATOR I MANAGER ❑ OrNERAUn+Dn®AGENT KI -Cont P`3 tom— <br /> IfAPR-CWs not Bre all-M Parry.proof of audiorhadon to sign Is required Till@ .. <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, the owner or operator of the property located at the above site address, <br /> hereby authorize the release of any and all results, geotechnical data and/or environmentaVsite assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as @ Is available and at the same time It is provided to me Or my representative. <br /> TYPE OF SERVICE REQUESTED: Tank Removal Permit <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER Cl <br /> V <br /> _IvW oA'M 'f-rM3 �N7y <br /> O/�l5/Oi <br /> INSPECTOR'S S NATURE: i C S I DATE: 6/5/00 <br /> APPROvmaY. ErPLfWEE#. DATE: <br /> ASSIGNED To: r( DATE: --62 — OD <br /> Date Service Completed (if already completed. SERWCE CODE: PIE: <br /> Fee Amount: o_�_ Amount Paid oZ Jra D� Payment Date <br /> Payment Type Invoke 0 Check I Li ReCeired By: <br />