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Oct 23 09 06:13a Reliable Petroleum: 209-845-8953 p.3 <br /> SAN JOAQUIN COUN'T'Y ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 7FATY ID# SERVICE REQUEST# <br /> 6 S � � <br /> OWNER)OPERATOR CHECK if BILLING ADDRESS <br /> Shln�-� S�12 <br /> FACIu1vNAME Ch04t„r W y (,kevroyi <br /> SITE ADDRESS 503 <br /> ��n ,� y�-�'.e I' V V G•� S"�' (.IL-"�)� 7 SZ(� <br /> Street Number OlreetlPn rw`” tree[Name Ci Zi Catle <br /> HOME or MAILING ADDRESS (If Different from SRO AddrOes) <br /> Siraet Number Stnat Ne <br /> CITY STATE ZJP <br /> PHONE 01 EM' APNM LANDUSEAPPLICAnONO <br /> laoq ) 992- hay 1& 50 -10 <br /> PNONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 010 1 1 <br /> CONTRACTOR! SERVICE REQUESTOR <br /> REDUESTOR . i0-ert- PST(a <br /> &V I_ ^ C..J_. GHeCK If BILLING ADDRESS <br /> BUSINEss NAME t pHOt)E# rf� EXT. <br /> � \I��l� 9&01e-LA-(P 1 Si°f V i ce S �Y1C,. �o $-/ l!/ <br /> HOME Or MAILING ADDRESS S2 � nf�V�,t t,n ,. 1 �u� ��.j.�t�.r}- (��rrJ {l� O f <br /> CITY GCA lL 00..1� 1 1�I (.� 1 `� tet-- J ! 'JJ STATE f-.�--` ,7ZIP Y6341- <br /> BILLING <br /> 6 3 !- <br /> BILLING ACKNOWLEDGEMENT: L the undersi.ned property or business owner, operator or authorized agent of same. <br /> acknowledge that all site andtor project specific ENVIRO\NIENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to 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 JOAQUTN <br /> COUNTY Ordinance Codes,Standards STATE and FEDERAL laws. �I ,„ <br /> APPLICANT'S SIGNATI-RE: 1� ` - �f�yt,�t,�,��,/ DATES-:/�/—/������ <br /> PROPERTY I BUSINESSOwNER❑ OPERATORt-MANAGER © OTHER AUI'ItOlt12EDAGE\T L' l.�+lt VI <br /> #APPLICANT is not the B,LLTAG PARTproof of atttkoriiatinn to sight is required 7irh <br /> AUTHORIZATION TO RELEASE IYFORIMATIOIN: When applicable, I, the owner or operator oCthe property located at the <br /> above site address, hereby authorize the release of any and all results, eeotechnical data and/or environmentalisite assessment <br /> information LO the SAN JOAQUIN COUNTY EIivIRO\MENTAL HE.ALTiq DEPARTMENT as soon as it is available and at the same time is is <br /> provided to Ine or my representative. ��,�,yy <br /> TYPE OF SERVICE REQUESTED: LL I T CYC qL a,rk� <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> OCT 2 3 2009 <br /> SAN IOAQUIN COUNTY <br /> HENVIROC)i NAL <br /> ACCEPTED BY: R. voLrf tr-Q..' EMPLOYEE �� DATE: tO 2'3 IQ U <br /> ASStGNEDTO: P. V11 U4. EMPLOYEEM e '31—) DATE: IU `O <br /> Date Service Completed (if already completed): SERVICE CODE: '7 PIE: 2260 <br /> Fee Amount: 3 Sr(jp Amount Paid 5 _ Payment Date b 2 3 U <br /> Payment Type V S Invoicef! I Dheck# 0O Z G— Received By: - <br /> GrW� <br /> EHD 48-32-025 <br /> SR FORM(Golden Rod) <br /> REVISE6 11/1712003 <br />