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SFRVICE REQUEST <br /> FACILITY 10# SERVICE REOUEST# <br /> Type of Business or Property <br /> ` BILLING PARTY <br /> Electrical Power Genera ion - <br /> OWNER I OPERATOR <br /> ACME POSDEF L.P. <br /> FAclurry NAME <br /> POSDEF Po <br /> SITE ADDRESS I West Washington Street <br /> $eNt NYM <br /> 2526 <br /> Mailing Address (If Different from Site Address) <br /> STATE ZIP <br /> CITY CA 95203 <br /> Stockton LUNO USE APPLICATION: <br /> PHONE#t � APN# <br /> 12091 467-3838 14 145-030-009 <br /> BOS DtsTRrT L.OaTtox OODE <br /> PHOHE#2 -- _ <br /> CONTRACTORISERVICEREDUESTOR <br /> BILLING PARTY❑ <br /> REouESTOR <br /> Andrew Safford P.E. PHONE# Ear. <br /> BUSINESS ROME <br /> Erler & FAX" <br /> h=HG ADDRESS 650 552-9012 <br /> v <br /> 1 STATECA LP 94010 <br /> OmBuilin ame <br /> BILLING ACKNOWLEOG'eMENT: 1. the undersiened property or business uvmer,operator or authored agent of same, acKnowledge that all she and/or project soecific <br /> PUBLIC HEALTH SERVICES ENVINO.NMENTAL HEALTH DIVISION hourly Charges a550Cated with Na protect or acunty will be billed to me or my business as Ion Codedentified on tan a ds, <br /> I also artily that I have Prepared this i aeon and that the M W be Performed U done in amnrdance wi h a0 SAN JOAQUIN COUNTY Ordman Codes,Standards,STA and <br /> FEDERALslYS. <br /> IL I A01 DATE: <br /> APPLICANT SIGNATURE: �/ <br /> PROPER IBUSINESS OWNER OP T IMANAGER OTHER AuTHQRM AGENT TNlle <br /> IIAPHTWr o nofeM BL'11T FN ,,pear ofauMeorOtlan ro s11m b hNlen <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property bated at the above sne address,hereby authorize the release of <br /> any and all results,oeoteUnial data andlof er1VlrOnmtmOl'Sda assessment inlomlation to the SAN.IOAOUW COUNTY PUBLIC HEALTH SERVICES ENNRONMENTAL HEUTN DIVISION a5 soon <br /> as 0 ts available and at the same Me it is provided to me or my representative. <br /> TYPE OF SERVIDE REGDESTED[ Oversight of in—place closure of used oil tank. <br /> COMMENTS: <br /> JN°°�E\soN <br /> g eSOE. `NEPMNpN <br /> CN�Pp[JM <br /> MASSIGHEDTO: <br /> IGNATURE: r CONTRACTOR'S SIGNATURE: <br /> : -(-. - //�� EMPL_:. fl: �/ DATE' ����' — Q 2 <br /> I) EMPLOYEE#: C DAIS: 11— /S_ 67.2 <br /> Completed ('rf already pletedj: SERVICECODE: - -` G' PIE 236 <br /> tAmount Paid �1 y1� . � Payment Datepe <br /> Invoice# Check# Received%r - " <br />