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FROM OIL EQUIPMENT PHONE NO. : 209 7545726 Nov. 16 2001 Oe:21RM P7 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID X SERVICE REQUEST C .,. <br /> OWNER I OPERATOR BILLING PARTY O <br /> Rudy Mendonca <br /> FAc0.11T NAME <br /> 3 Palms Groc-erlz <br /> SDE2Ess E Waterloo Rd. <br /> 67332 anxexwid. oareeen msrtx.an aye <br /> Mailing Address (If Different from Site Address) i <br /> city STATE LP <br /> PHONEN'I eu. APNO 1-moUstt APPOCA710Ntt ' <br /> (209-931-6048 <br /> PHONE 22 m. BOS DemicT LOCA71ottCooe <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REDUeSTOR BILLING pARr rel <br /> Keith . A. Tallia, President <br /> BUSINESS NAME PHONE 0 m. <br /> Oil Ecruipment sgryinA onca754-1 <br /> MAaING ADDRESS FAX# <br /> P.O. Box 950 <br /> Cm San Andreas STATE "95249 <br /> BILLING ACKNOWLEOGEMr.NT'; I,the undersigned property or business owner,operator or authorized agent of same,admcwledge that all site and/or pmiLd specE <br /> PUBIC HE4LrN SERVICES Elva uourrAL Vt&TH QMLWN hourly charges a=dated with this pmlect or acsvny we be tiled in me or my business as idemoed on this tiro, <br /> 1 also certify that I here prepared this application and mat the wo wit be doa�banoa wim all Joaaw COUNTYOMlnance Codes,Standards,S7AIE an <br /> FEDERAL Iowa. <br /> APPLrAN &GkATuaa: Keith A. Tallies r DATE: 7/23/01 <br /> PRQPERTY/BUSINESS OWNER 0 OPRRATORIMWGER ❑ OTHERAUIHCRfLEDAGFNT IX Agpni- <br /> BAPplWranrtan Pwry prop/olaulhwipdon bsign ixrpusd TRIA <br /> AUTHORIZATION TO RELEASE INFORMATION:When appGgbie,I.the owneroroperator ofineprope:rykonedatfieabove sbaddress,heretyw orizatheream< <br /> any and as msurs,gemedmiral data andfor envuonmenaYslte:s,es<nem niamadon to me S,w JOAwIN CGv;Nrr p•:r�n^HP�,IT15cavt[E5 EednGNuprAl FiEx�t DrnssR as sae <br /> as a h available and at me same time itis provided to nre or my rvrw,•,ertmdve. <br /> TYPE OF SERVICE REQUESTED: Permit application to install under pump containment pane. <br /> CDMM'cNTa: <br /> INSPECTOR'S SIGNATURE: L:ONniACTOR'S SIGN:.TUY.I: <br /> APPROVED BY: EIIPLOy E t DATE: <br /> ASsiamEp TO' EMPLOTP1Ir: —• •DATE: <br /> Date Service Completed (if already mmpleted): —1�- SERvrs CQQe: PIE: <br /> Fee Amount: Amount Paid .. Payment Data <br /> Payment Type invoica x l -- Check k Received ey: <br />