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Jan 16 13 03:06p Reliable PelroleumA 20M45-8953 p.3 <br /> AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Nierty FACILITY 10� SERVICE REQUEST* <br /> OwNERI OPERATOR <br /> ¢/ n CHEC!(If RILLINGADDRFSS <br /> FACILITYNAME <br /> SITEADDRESS 5—Wit H <br /> Sheet D! Ueel <br /> HONE or MAILING ADD (M Different from Site Address) <br /> SUeo[N�mher —Stmet Name <br /> CITY 5-tv, y STATE zip <br /> PHONE#I Ems• APN t• LAND USE APPLICATION R <br /> 001) R�(6` y <br /> PHONE12 Ea. SOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQ TOR �a I -� CHECK If BILLING ADDRESS <br /> BUSINESS NAIVE ♦! T PHoft:# <br /> HOME or MAILING ADD stVC, <br /> i% taT' Gj STATE zip <br /> BILLING A KNOW EDGEMENT: 1, the undersigned property or business owne , at "athorized agent of same, <br /> acknowledge that all Si and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly asSODiated With this project <br /> or activity will be billed o me or my business as identified on this form. <br /> I also certify that I have irepared this application and that the work to be performed will be done in accordance with all 3AN JOAQUIN* <br /> COUNTY Ordinance Co s,Standards,STATE and FEDERAL laws. -2 <br /> APPLICANT'S SIGN TUBE: _.. .. �`��-may- �. 'f " e DATA: <br /> PROPERTY/BUSINESS Ow ERO OPERATOR IMANAGER LI OTHERAt:rRoRizEDACENTd � )y-- <br /> {-APPL!c hr is not the Btcuvn PA.47Y.proof ofauViorizadon to sign is required Title <br /> AUTHORIZATION T RELEASE INFORMATION: when applicable, I, the owner or operator of the property located at the <br /> above site address, h by authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my re resentative. <br /> TYPE oTF SERVICE REQUEST <br /> COMMEms: �e2 Ji f fiLS 3SQ `�o 6e. 0-01dS'-C,U Gy--,, tt5f13 <br /> ACCEPTED BY: G IJP EMPLOYEE 4: DATE: <br /> ASSIGNED TO: /t EMPLOYEE#: DATE: <br /> Date Service Complete (if already completed): SERIKCE OwE: PIE: <br /> Fee Amount: Amount Paid 3"'11Jr ()b Payment Date <br /> Payment Type invoice p Check# ecelved By: <br /> EHD 48.02-025 l.F) 1 S-� 1 <br /> REVISED 1111712003 SR FORM(6o;den RDtl) <br />