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Oct 02 08 11;37a Reliable PetroleumW45-8953 p-3 <br /> 4 0 .SAN JOAQUI N COUNTY ENVIRONMENTAL HEALTH DEPARTNTFNT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C-1 . <br /> OWNER/OPERATOR <br /> CHECK it BILLING ANDRESS <br /> FACILITY NAME <br /> SITE ADDRESS jhrrjon— <br /> Street Number Diretion Street Name <br /> Zi Cade <br /> HOME or MAILING ADQRESS (If Different from Site Address) 777 Ci <br /> y� - 17 <br /> CITY <br /> Street Number Street Name <br /> - <br /> STATE zip <br /> PHONE#1 APN# LAND USE APPLICATTON# <br /> (2v9 ) 93-- 15�C Ear• <br /> PHONE#Z ExT. 1305 DISTRICT 7LOCARON CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQU"ESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BuswasS NAME ♦ 1 <br /> Pc,r} ��Ea-r. <br /> ROME Or MAILING ADDRESS �1 FAX# <br /> � (� �y ��'� �4�ti�C�1 i'� ..�.-��U i�, cj"�'• P� <br /> CITY Lt 4`-' STATE C ]V ` ZIP <br /> BILLING ACKtNO1VLEUCEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and'or project specific ENVIRt7NNIF_NTAL HEM,Ti-I DEPARTMENT hourly charges associated with this project <br /> or activitywill be billed to me or mg 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 SA"q 10AQUIN <br /> COUNTY Ordinance Codes,Standards,)S' ,ATE and FEDERAL.aws. <br /> APFLIC. T`S9[GNATl1RE: DATE: 2— J <br /> PROPERTY i BUSINF,S'S OWNFR0 OPFRATOAI NIANIGER D OT11[?R AUTHORTT-F,11r�CC\T F� 1 If I, �G(� L <br /> if RPPt�C:t.�T is not the BILLING PARY proof of authariz-ation 10 segv is required rifle <br /> AUTHORIZATION TO RELEASE INFORMATION: when applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and,-or environmental/site assessment <br /> information to the SAN JOAQUIN''COUNTY ENVIRONMENT-41-HEALTH DEPARTMENT as soon as it is available;and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SEMACE REQUESTED: <br /> COMMENTS: <br /> y �Q <br /> ik <br /> .l.,'L ulT!37l:% . <br /> L>✓L .' t, <br /> Cray -t ;tel .mac c �vs sA1 jopoUm ccs . <br /> ENV19ONMF T <br /> viEALTH[)F-PART <br /> ACCEPTED By: 14 EMPLOYEE#: DATE; <br /> ASSIGNED TO: EMPLt?YEE#: DATE <br /> Date Service Completed (if already completed): SERVICE CODE: P1 <br /> Fee Amount �' Amount Paid } Payment ate l b 'L b �C <br /> Payment Type Invoice# Cyt# <br /> G Z4-{ (� Received By: <br /> EHD48-02-023 G <br /> REVISED 11/1712003 SR FORM(Golden Rad) <br />