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• SERVICE REQUEST EHOO6ISR revised 09/04/98 <br />Type of Business or Property FACILITY ID # C SERVICE RE UEST # <br />Water Service �, `,�,'°-�%(; / .Sr <br />OWNER/OPERATOR California Water Service Company <br />FACILITY NAME Equipment Yard <br />SrTE ADDRESS 1602 E. Lafayette stN <br />Street Number DlreWee <br />Mailing Address (If Different from Site Address) <br />Same as above <br />CITY ---J-STATE <br />Stockton, CA <br />Ext. APN # LAND USE APPLICATION # <br />P"�i'�� 464-8311 <br />PHONE 92T• BOS DISTRICT <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Jim Thorpe Oil, Inc., Richard Thorpe <br />BILLING PARTY <br />St. <br />Type suite 0 <br />zip <br />95203 <br />LOCATION CODE <br />BILLING PARTY ❑ <br />PHONE <br />BUSINESS NAME # <br />Jim Thorpe Oil,Inc. (20P 368-6175 <br />MAILING ADDRESS FAX # <br />P.O. Box 357 20 368-1851 <br />CITYLodi , STATE CA ZIP 95241-0357 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same,, acknowledge that all site <br />and/or project specific PUBLic HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br />Ordinance Codes, Stand STA FEDERAL I <br />.,�. VCs. FIC -2 � DATE: 11/13/00 <br />APPLICANT SIGNATURE: <br />PROPERTY I BUSINESS OWNER OPERATOR! MANAGER ❑ AUTHORIZED AGENT C o n t r a c t o r <br />If AparAwT Is not the Bum PARTY, proof of suflrorhadon to sign is requM Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 environmentallsite assessment information to the SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL 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 />.Tank removal permit <br />_ <br />COMMENTS ❑ <br />SPECIAL CONDRION(S) OF APPROVAL ❑ <br />OMER <br />Rr�,G <br />aA <br />TT'7 FNj PON""v*\ �"i •.' <br />INSPECTORS SI RE: <br />RAS �STUR <br />I DAA' 11/13/00 <br />i <br />APPROVED BY: <br />EMPLOYEE # <br />DATE: <br />ASSIGNED T0: <br />``SERVICE <br />EMPLOYEE 9: � � <br />DATE: <br />Date Service Completed (if already completed): / <br />CODE: <3 <br />P 1 E: , <br />Fee Amount: le_i <br />6� <br />Amount Paid <br />!� <br />Payment Date ! Q <br />Payment Type <br />I Invoice # <br />I <br />Check # <br />Received By: <br />