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Sep 22 08 10:38a Reliable Petroleum 209-845-8953 p.3 <br /> 0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICER QUEST <br /> G -DF <br /> OWNER OPERATOR <br /> Mbt'1&M1rftCt <br /> 2-K/61-,PiCHECK If sILLING ADDRESSFAcIuTYNAME 1I , GA5o Ni l� 4 <br /> SITEADDRESS rit.! 1 <br /> er + / }� <br /> Street NumbOirecllon Streel Narne J city7� Code <br /> HomE or MAILING ADDRESS (If Different from Site Address) <br /> _ Street Number reetName <br /> CITY STATE zip <br /> PHON C 1 t 1 r EXr- APN# LAND USE APPLICATION# <br /> PHONE#2 En- BOS DISTRICT LOCATION CODE <br /> I 00q ) d'i I- d22 J1 UC3 l <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQU EST012 <br /> CHEGKIfBILLING ADDRESS <br /> BUSINESS NAME ' <br /> PHONE4 Em <br /> HOME Or MAILING i41]DRESS I�CL� ll �� ( � `. FAx <br /> ar`1 � - ��- <br /> -7 -J- 4�v�) r <br /> CITY " a j-e STATE C7� ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acicnowledge that all site and/or project specific EN-VIRONMENTAL HEALTH DEPARTMENT hourly charges associated With this project <br /> or activity will be billed to roe 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 JDAQLnN. <br /> CouNTY Ordinance Codes,Standards, TATE and FP-DRR-A L1aws. p <br /> APPLICANT'S SIGNATURE: DATE <br /> PROPERTY IBUSINESS OWNER0 OPCPATORI1'LkfVAGER (] OTIi6RAuriio IZGnAGENT M (,} , 4 f` <br /> /f.$PPL1C,JNT is nod the BILLt,'I PART');proof of authorization to sign is required Time <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 environmentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE 1R.Tloon as oon as it is available and at the same time it is <br /> provided to me or my representative. U r�T �.�Q. r-��} <br /> 0-- <br /> TYPE OF SERVICE REQUESTED: to l ace. M.U D o n .Al rd Cq( .e p II o d t, c-J- <br /> COh1MENTS: = y i[t f YtCkM l� 1�UYti �Ct"I <br /> C-l'i J <br /> el-4A ��.vtI{=camC�Pf� et St; tett �ilf� - <br /> s O151T1 jy�CAt- <br /> AcGEPTED BY: r r f uQ_� EMPLOYEE#: iI'� DATE <br /> ASSIGNED TO: /2,, t fV(f Y��' EMPLOYEE#: e31-1 DATE: <br /> Date Service Completedv(if already completed): SERVICr:CODE: � Pl:: V <br /> Pee Amount; �l r Amount Paid 3` S (Sb Payment Date aq <br /> Payment Type Invoice# Check# 1_�5 2 11eceived By: <br /> EHD 48-02-025 ill- SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />