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SFRVICF RFOUFST Willi <br />Type of Business or Property <br />-Es <br />--- ---- - - <br />BILLING PARTY ❑ <br />FACILITY ID #SERVICE <br />s� <br />REQUEST # <br />l0 3 <br />mot oct< F-JLL SAI <br />MAILING ADDRESS P O X <br />F6 OGO <br />s2 <br />CITY h10 O �S N <br />BILLING PARTY <br />OWNER I OPERATOR <br />bbiJ I -k 'D <br />FACILITY NAME �-N I T•O OIL— <br />IL--SITEADDDREESS <br />SITE ADDRESS <br />'�p . <br />Ha�taa Roe��� <br />o -1 I D strM xumEs <br />DL don <br />5!'Mxame <br />Type <br />sexex <br />Mailing Address (If Different from Site Address) <br />3L1so E� CAmt�o <br />CITY C c R E <br />STATE zip (1 5 3 0- <br />_f <br />PHONE#'I <br />APN# <br />LAND USE APPLICATION# <br />Q()S 1 s3 - IDT? <br />PHONE#2 Env <br />BOB DISTRICT <br />- LOCATION CODE <br />REQUESTOR <br />BILLING PARTY ❑ <br />S�. CAD <br />BUSINESS NAME S �-� <br />PHONE# 7 <br />09 <br />MAILING ADDRESS P O X <br />FAX <br />5# 5- r a aq <br />STATE � zip 953sa-saw <br />CITY h10 O �S N <br />BILLING ACKNOWLEDGEMENT: I, the undem4ned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specfic <br />PUBUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourty Clangrad with this project or activity vn0 be billed to me or my business as identified on this fonn- <br />I also certify that I have p this plication and that the work , be edo done in accordance with all SAN JOAQUIN COUNTY Ordinance aL Standards, STATE and <br />,FEDERALla <br />. PLICANT SIGNATURE: DATE: <br />PROPERTY I BUSINESS OWNER OPERATOR I MANAGER ❑ QM ® <br />ELAUrHCRAGENT ❑ Title <br />If APPUWrFi$notdo9MPAmY Produf u0..We, b Aqe arewired <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorae the release of <br />any and all resuls, geotechnical data andlor emironmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EMMONMENTAL HEALTfi DNISION as soon <br />as it is available and at the same time his pmvided to me or my representative. <br />TYPE OF SERVICE REQUESTED: ko-cw'- O�- I () <br />COMMENTS: <br />APPROVED BY: <br />I5L000 GRO. �1i.SiL V_S,T• �.Qt1Pt�LSuRS <br />PAYMENT <br />RECEIVED <br />EMPLOYEE#: - I I DATE: <br />MAY 312001 <br />SAN JOAQUIN COUNTY <br />PUBLIES <br />ENVIRONMENTALLTH HEALTH�DIVISION <br />�- - — EMPLOYEE#: DATE: <br />ASSIGNED T0: <br />Date Service Completed [If already completed): <br />SERVICE CGDE: (�. 3 <br />Amount Paid Payment Date <br />Fee Amount <br />Payment Type1 " ` invoice# Check# <br />3N . o0 <br />Reteived By: <br />