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SFRvlr..F REQUEST EHOO61SR revised 09/04198 <br />Bus Terminal FACILITYID# <br />SERVICER f$7050 <br />Type of Buse roperty <br />1 <br />1 <br />BILLING PARTYw <br />3 OWNER/OPERATOR <br />! Arnie Taylor <br />A <br />FAcILRY NAME <br />Taylored Tours <br />(20V <br />SITE ADDRESS 330 East Kettleman <br />sm.e <br />sa.a NumOa �^^ m«Hae.e <br />FA%# <br />Mailing Address (If Different from Site Address) <br />MAIUNG ADDRESS <br />P.O. Box 357 <br />1912 E. Mettler Rd <br />(209 <br />368-1851 <br />STATE zip <br />CITY Lodi, <br />Zip 95241-0357 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #1T• <br />09 334-3452 <br />PHONE #2 En. SOS DlsrRlcr <br />LGcanQN CGDE <br />ACTOR f SERVICE REQUEST uR <br />REQUESTOR Jim Thorpe Oil, Inc. <br />BILLING PARTY❑ <br />❑ <br />PAYMCOMMENTS <br />_._ RECEIVE <br />RECEN!�� <br /># <br />BUSINESS NAME <br />(20V <br />368-6175 <br />INSPECTOR'S SIGNATURE: - C - w ' RE: <br />FA%# <br />APPROVED <br />MAIUNG ADDRESS <br />P.O. Box 357 <br />(209 <br />368-1851 <br />CRY Lodi, <br />STATE CA <br />Zip 95241-0357 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent or same,. du IvwiR wo u— — — <br />and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVIGION hourly Charges associated With this project or activity Will be billed to <br />me or my business as identified on this form. <br />I also certify that I have prepgped'B, appliW=r3 ,1�wolk to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br />Ordinance Codes, Stan <br />APPLICANT SIGNATURE <br />DATE 9/30/98 <br />PROPERTY/ BUSINESS OWNER 7 y�Contractor ❑ OPERATOR MANAGER - OTIiElt AUTHORIZED AGENT T2 <br />.Contractor <br />is not the 8WNG PAaty proof of authorization 10 Sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmental/site assessment information to the SAN JOAQUIN COUNTY <br />P I HEALTH SERVICES ENVIRnNMENTAL HEALTH DIVISION as soon as R is available and at the same time it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />Underground tank removal permit <br />11 SPECIAL CONMON(S)OFAPPROVAL❑ OTTIet <br />❑ <br />PAYMCOMMENTS <br />_._ RECEIVE <br />RECEN!�� <br />OCT 2 1998 <br />SAN JOAQUIN COLNTY <br />PUBLIC HEALTH SERVICES <br />CN I <br />INSPECTOR'S SIGNATURE: - C - w ' RE: <br />D Lir <br />APPROVED <br />EMPLOYEE#: OJCJ ( <br />ATE: (L) _7qJ.`� <br />EMPLOYEE#: <br />ASSIGNED TO: l` 1�1i III) <br />.Date Service Completed (if al SERVICE CODE: <br />ady completed): <br />Fee Amount � Amount Paid <br />DATE: y <br />v 3 Pi 7O <br />Payment Daty - <br />�O <br />Payment Type <br />ktvolce # <br />Check # <br />Received By: _ <br />V <br />