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S;RvlcE RECUEST <br /> Typ, f Business or Property FACILITY 10,: �% �, ;C,' �; SETACE RECUEST <br /> Service Station 2 f (, ( :S/ CC, .3 <br /> CWiIFI OPERATOR BLLL'NC PARK tS <br /> FAMIrY E <br /> � UCL � • Y' 2 \ <br /> C _ A..4a Olden �/� 1`�L /+V Sr .gae. TV" s�tl.a <br /> Maiiing Address (if Different Rom Site Address) <br /> 95205 <br /> Carr ATE ZP <br /> P40NE*1 W. AP4I Lva USEAFPt.'GTION,: <br /> PKNE 42 as scs 01S M. LccAT>a _ _ <br /> N CJCE: <br /> f <br /> CCNTWA4tCR1 SCRYuC�RECUEoiCR - <br /> Rz=ESTOR R" PARrr❑ <br /> Jim Thorpe Oil , Inc. <br /> BUSMSS NALE 368-6175 <br /> Mm�mf;AocRess P.O. Box 357 I F 6 368-1851 <br /> Gr Lodi , CA STATE ZP 95241-0357 I <br /> BILLING ACKNIMLEDGEMENIT: I. the wdersSned property or business awnw,operator or aufhorcad agem of same,accnwiedge To ad site ardthr piojea speck <br /> Pusn..c HEALTH SERVICES E GMe6AL HEM. msax,nowy charges asmcod wdh to projector av::vity mw be biled to me army business as�dit tl on no br n. <br /> I aoo aevfy tat I have Porll <br /> Ghat 1,7&b be •ed be date in ac=rdwm with aA Sm.'CACIav Cantu Ommeoa Codes,Standards.STATE and <br /> FAL ER �avm ek1PPUCANT SIGM-7 PE'e ♦i\ -'L��` �-o�� OATS I - 1 f - i <br /> til <br /> PRCPERrr/Eusa+ESS CWNE.R ❑ CPERATPA/MANAGER ❑ Cr ERAUDUU 7AGEW IZ/ <br /> tl.hPP..Gwrsn�taE[trcP.arr.>toafafarrowmdan foss rianmriW rifle j <br /> AUTHOR¢1TICN TO RELEASE INFORMATION:When app6r3hk 4 Che ownroropw=aid*property bated atlte above site address.hevty authann ne mleaseaf <br /> any and ad rft geotecmal dam andlCr amuonMet>alfsite assessment inicrnwfrm fo In SM XAam/f..71NTY P'3Lc HErLTTi S—aAas EwwcmeaiL HEuii 0M=N as soon <br /> as lis available and at the same$ne a provided to me or my mwesut aove. <br /> TYPE OF SeRvlc RECUE=: S <br /> Tank Removal Permit <br /> . vpN�p NaP`NS RS aNIS4�N <br /> Bt•ICNEN NFP <br /> PU tPl <br /> �Nul�orJ <br /> i T 1 , Inc. / <br /> VISPEC.OReS SIGNATURE CCxrrncmFes gm--- URE b v <br /> APPRaie ay: —r . I i EyPt^r`t. C D `I-10/21/03 <br /> Asswetim: : E1w_OTE DATe <br /> : Date Service Completed (if aiready completed): I Sewca-CaCE: L/ P I'E_ 23e' <br /> he Amount �—Z. I Amount Paid 1$ PSymernt ate to 2203 3 <br /> Paynnent i ype v." Invoice I I Check X SS� I Ret ived By: <br />