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Oct 26 12 09:55a Reliable PetroleumA 20M45-8953 p.3 <br /> AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> .SERVICE REQUEST <br /> Type of Business or PitFACILffY ID# <br /> SERVICE REQUEST# <br /> dOWNER J OPERATOR a ale <br /> (;,Lt <br /> CHEGtIf BILLING ADDRESS <br /> FACIDTY NAME <br /> WEADDRESS t-} h' c, <br /> � 4u ✓ q' <br /> eeN beb17 7Z i <br /> CI <br /> HOME of IMAll1NG ADOKtZPS IN Different from Site Address) coa <br /> Cm Strcet maer s <br /> STATE Zip <br /> NONE#1 E"' APN# <br /> (aoy ) 9yg-�+j jf LAND USE APPLICATION <br /> PHONE#2 Ev. <br /> ( ) HOS DISTRICT LOCATION CODE <br /> CONTRACTOR /SERVICE REQUESTOR <br /> REQUESTOR �` ! '�, <br /> �ltiCl � - Sa"C eZ_ CHECK If 84.UNG ADDRESS <br /> BUSINESS NAME D t tt- PHONE# Err. <br /> F t �1-role��n� 5'�e.r�tr_ts enc.. y <br /> HoN¢or MAILING ADDRE <br /> IIr13o k+orSPsh., c_ fzoc�t i,�u4) <br /> CIN p O_ e r k.e <br /> STATE C/r Zip `�S 3 Gi <br /> BILLING ACIQIOWL DGEMENT: I, the undersigned property or business owner, operator or authorized agent of Same, <br /> acknowledge that all site d'or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed t me or my business as identified on this form. <br /> I also certify that I have epared this application and that the work to be performed will be done in accordance with all SAN JOAQUW <br /> COUNTY Ordinance Code ,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNA URE: <br /> ry DATES /:, It ^�5—/2 <br /> ElPROPERTY/BUSINESS O OPERATOR f MANAGER ❑ OTHERAUTr10RIZED AGENT o �' <br /> JfAPPLIC.a 'T is not rhe SILLRVGPARTY.IrrvW of authorization to sign a regsired L d/ti Y��e r <br /> AUTRORIZATION TO LEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, herel y authorize the release of any and all results, geotechnical data and/or environmentalisite assessment <br /> information to the SAN J01 QUIN COL,'N7Y ENVIRONMENTAL HPALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my repn sentative. <br /> TYPEOFSERVICE REQUESTED: <br /> COMMENTS: <br /> RECEIVED <br /> OCT 262012 <br /> SAN JOgOUIN COUNTY <br /> ENVIROMENTAL <br /> ACCEPTED BY: EMPLOYEE M <br /> ASSIGNED TO: DATE: <br /> EMPLOYEE M <br /> DATE: <br /> Date Service Completed (F already completed); <br /> SERVICE CWS: PIE: <br /> Q <br /> Fee Amount: Amount Paid Pay nt Date <br /> PaymentType <br /> 1U 17 <br /> YV a Invoice# C A V Z Reeelvad Ery: <br /> EHD 48-02-025 �l <br /> REVISED 11/17/2003 ' SR FORM(Golden Rod) <br />