Laserfiche WebLink
Oct 13 11 05:04p Reliable Petroleun-A 209-845.8953 p.3 <br /> 1 <br /> AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Proq arty FACILITY ID# SERVICE REQUEST# <br /> G A1= 3� 20 SKoo3� <br /> OWNERI OPERATOR ` <br /> �,,_ 3 Q� •�` CHECK If BILLING ADDRESS 0 <br /> FACILITY NAME [r Yt,(IJt ik ��J„`�' ei / rdpi <br /> SITEADDREss is-01? <br /> '^ / tm!` �r 1 <br /> Street N mbar I Dimctbn et Name ' Ci Zi Code <br /> HOME Or MAIUNGADORES (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE 2AP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (.Xq) qg2-- 1-1 <br /> PHONE#2 En. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> RELIUESTOR /1 ��� <br /> �r �. CHECK If BILLING ADORES <br /> BUSINESS NAME /L' PHONE EXT' <br /> HOME Or MAILING ADDRI SS 11R�o 1��,��ij/ 'e_ FA%# <br /> , ,?) <br /> I I't: 0 O/'S 5W3 <br /> CITY &'k. STATE ZIP 153101 <br /> BILLING ACKNOW EDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all si I and/or project specific ENVIRONMENTAL HEAT.T'H DEPARTMENT hourly charges associated with this project <br /> or activity will be billec to me or my business as identified on this form. <br /> I also certify that I ham prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Co les,Standards,9rATii and FEDERAL laws. <br /> APPLICANT'S SIGN TURE: , ,r°ter DATL: I/f <br /> PROPERTY/BUSINESS O 'ER❑ OPERATOR!MANAGER If OTurRAUTHORIZEDACFNT'� C6✓l i� c `a <br /> If APPL7 ANT i5 not the BrLL1•eG PART:✓ proof ofauthorl,',ation to sign is required Title <br /> AUTHORIZATION RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address: h eby authorize the release of any and all results, geotechnical data and/or environmental!site assessment <br /> Information t0 the SAN OAQUM COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time it is <br /> provided to me or my r resentative. <br /> TYPE OF SERVICE REQUES ID: &Vs4rki t EC NT <br /> COMMENTS: e-r�'1 V1� ,,,•>0 �i> r� RECE VED <br /> OCT 1 f 2011 <br /> SAN JOAO IN COUNTY <br /> ENVIRO MENTAL <br /> HEALTH D PARTMENT <br /> ACCEPTED BY: EMPLOYEE#: / DATE: /0 <br /> ASSIGN ED TO: , EMPLOYEE#: Np/ DATE: <br /> Date Service Complet d (if already completed):-W57 I SERvICECODE: ���+ Pf <br /> Fee Amount: O-L' Amount Paid 3-7S. O D Payment Date l pI It It <br /> Payment Type V14 Invoice# �.t-• (f, 1 Check# Received By: <br /> EHD 48-02-025 -"� ` ` SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />