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SE]RVYCE RECUEST <br /> Type of Business or Property FACIrrY 10 T SF—TACE RECUEST: _ <br /> Petroleum Pipeline Facility ZC 5 ti _,� f�C'C; Z -I ) <br /> CWNERI CP--4ATCR HL.M.PARTY Cj <br /> S. T. Services <br /> FAczmNAnrE S. T. Services Pipeline and loading facility. <br /> SuEAcORESS 3505I Navy Dr. <br /> sww4ure. OU.'. st.a!Iaw iYa. I saa,i <br /> Mailing Address (if Oiffererrt from Site address) 2941 Navy Dr. <br /> ZP <br /> C17Y Stockton, CA 95206-1149 <br /> P4CNE*1 ea APN M LANo USEAPPI:CAMN R <br /> V09) 943-5662 . <br /> PHONE 2 20. HCS 013TRIC: L^cATiaN CJCE:. <br /> . - - ---CCN7RAC0ti 1 3L-0rCF RFCUE'TCR <br /> RE=E5 roR BILLM PARTY C <br /> Jim Thorpe •Oil , Inc. <br /> BuwESs NAME PHONE:4 <br /> ( 203 368-6175 <br /> MALm I <br /> °D°Ras P.O. Box 357 �2i0368-1851 <br /> Cr Lodi , STATE CA ZtP 95241-0357 <br /> BILLING ACXNCWLECGF—VENT: b Tse undersigned property or business owner,operator or audmor urd agent of same, admcwteoge riot ad ste andrr xc*—*sce=5 F <br /> Puet_C HE cH ScfiRCS EwrRGvAETAL HEAL'}+Ctv sm houny urges assocamd with osis project or a=vtt mw be baled b me or my business as tlerttitied an this arm <br /> I also:a(*drat 1 have preoptdthis acpr=ticn and=ase weft to be perfomsed wd be done b ac=rrdanm wM ad Sm 'cA m CawTy Crc nsnce Cades.Standards.StATe and <br /> FEEvt!VM ; <br /> 3 <br /> APrK uNT SiGHA vRE <br /> PRCPC-qTYISUSNESSCWNER t CP-ATCAIMANAGa C CTIRAurrCR=AC,c1T C <br /> rAANX.wrS ra 7sft-ACPour.Prodof wd==darr to sign a mquisd Title <br /> AUTHCRlZA7CN TO RELEASE INFCRMATICN:'Nhen apokable.4!se awner or operator of to property orated at ne above site address hereby authority ate mime of <br /> any and ad resurts,geotecsmcif data arxdlar emrironrtsemaltsde assessrttent niorttsaticrs to to S,w rCACun+G'uNrr p,-2L C E+LTFr Sc'Ac— EwsRCru�rrx HE v.H CtVtSCN as soon <br /> as t is available and at dse.same ane its provided to me or my representative. <br /> TYPE OFSm-4vr---REcues7m: Underground Tank Removal Permit <br /> CoMMEiiTS: �G n K f PAY iVI E N-T <br /> RECEIVED <br /> k <br /> DC . � + <br /> t <br /> AN JOAQUIN COUN-fl <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH CM810, <br /> i <br /> INSPECTCR'S SIGNATURE: CcxrRAcmR's SiGNATuR$ <br /> APPRCvm HY: Y(A��, `. J r�. i FJ'irC.1'�� Z L,a DAit'• t � �� �/ <br /> ASsiGNEoTo: 1 `11,1` /1 ElIPr1]YE=s �. ( DATE: <br /> Dam Service Completed (if already caU mp Sr-W=-Sr-W=-CocE: �,-3 P I E: <br /> he.amount1; I Amount Paid Payment Cate <br /> Payment Type ! Invoice I c I Check; 3 ! Received Hy: <br />