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Dec 26 13 11-.24a <br />JP Petroleum service <br />916-372 <br />"'CEIVED <br />SAN' JOAQUIN COUNTV ENWRONMENTAL HEALTH 0FPARTAAF=K1' -`� 2 6 201,3 <br />SERVICE REQUEST <br />Typo of Business or Prcpl-tyFACL r-,. Iii <br />EP L <br />irlar, r -m <br />rzuz'�-rs <br />OWNER 1OPERATOR <br />31"_s R.-p--osa <br />FAC?L1)VNiV,% <br />%TE A.00;;ESS <br />HC?.IZ or MAILImc ADDRESS (if Offferant from Sire Addram� <br />clry <br />CZ1. --TAPH -10 <br />(209 ) -z..- 1 <br />LAND UGr App-icw710n e, <br />-OCA710k CODE <br />C'0NTRA%"-`T0iZ/'S2R%!jC2 REQUESTOR. <br />!�!!EREQUF-STOR 4 - I' - — — <br />( � I - IC � . �- _. I C-,-ZCe if BILL= ADII.E.XI <br />BUSINESS NA.Mrz <br />t R.wtL it Exi <br />Hatir. or MAww; ADDRESS <br />T'T <br />STA72 <br />BILLING ACKNQWLED9EMENT: f. t to u7carsigned property <br />ness owne.. upe�,ato- -r eaut.� <br />ackWM,ed e Mat all 5�,e aicUor Proic,: specirin Cr�=.rges ZSS00'atrec <br />9 orizod agent ot same, <br />VAI w �)ifle6 to me or my busitless as ide-110ilid Cn 1�.it m. h. ti is prorect or <br />a- for <br />I also Ger+rfy that I havc Prerared tliis appucrai,on ar-4 -ta! The !3:R ucrionre.-j .vir e;e dc.,%c :n V=-rcarpe ati -A <br />�,m <br />C3U�17( OrOnantx Cocj&s, Sldr7d'ard5 JVAri }7i: <br />APPLICANT'S SIGNATURE: <br />lz�tCIP-ERTY!SUSINCSS CWNtR trb bPERA-,GR I MANAGLA ZI <br />A P.=�ucq . . i <br />-,F- �s rO,, <br />AUTHQRIZATION TO RELEASE INFORINIA <br />CaO;5- X GPerato�- ---,f ihr rzooert�,r lz-=�ec 3" ap'nave <br />site address, heaby- authorize fne re�ens-iz ct �i�" anu Zli! GSF -_.,tC <br />tC I 'ess _r.,, ? ff, -- rat i -* r <br />hf; S'. N* JCIA.zu 114 Cowl, 7Y Ei 4 <br />my representative. <br />TYPE OFSERIACERZQUESIED: <br />AGCEFTEEO SY: <br />ASSIGNED TO: E-M-FLOYE4. 4: DAIL: <br />Date ServiceCompleted (Ifalraacvcomploted): <br />Fee Amaurit; Arnount Paid 1 Pa; mens Data <br />Payment Type Invoice* <br />Received By: <br />EHD 48-02-D25 <br />07117,% <br />