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May 31 12 09:33a Reliable PetroleumA 209-845-8953 p.3 <br /> S JOAQU*OUNTYENVJRONMENTALHEALTIREPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Propie tY FACILITY ID# SERVICE REQUEST# <br /> 5L 0m4 s5-0 <br /> OWNER OPERAAT(/ORS I�/ ( / � ' CHECK If BILLING ADORESS❑ <br /> FACILITY NAME✓ AtC'L1 <br /> SrrEADDRESS ' 1 CS S • 5- -1.� �()i,�'CC�C77 J-4�. �( "Zj� �j s'Z,j`J <br /> `1 SIMM Nu w t 1 L c <br /> HOME or MAILING ADDRESS I f Different from Site Address) <br /> Strvm NumesrStM&I Name <br /> CIN STATE ZIP <br /> PHDN01Pxr, <br /> APN9 LAND USE APPLICATION ft <br /> (a0q) 993-'2' � � <br /> PRDNE#2 Err. BOIS DISTRICT LOCAnoN CODE <br /> l ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR &JCHECK if Blu.wc ADDw--=Gd <br /> BUSINESS NAME J ILrw. Q r PRONE ^ �. <br /> i �a�r!lCu,19 ;. �•ry%c.es <br /> HOME Or MAILING ADORES 1 J n LL {� n • (AX$ d) f�`ivs-- 3 <br /> CITY (✓t� STATE ! ZIP <br /> B LUNG ACKNOWLI DGEM)ENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site md1or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be bil led t me or my business as identified on this form. <br /> 1 also certify that I have p epared this application and that the work to be performed wil I be done in accordance with all SAN JOAQt;IN <br /> COUNTY Ordinance Code Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNA RE: r —3D-1 DATE: <br /> (✓ j L <br /> PROPERTY]BUSINESSOWH ❑ OPERATORJ MANAGER ❑ OTHER AUTHORIZED In <br /> AGENT oryIjro-cie <br /> if AP°LlcA r is not the Biwmg Pnxtr proef of authorization to sign is required Titre <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the <br /> above site address, here y authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JO QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my repr sentative. <br /> TYPE of SeRvICE REQUESTED + •�'� �j JiLl,yy�p r U VA r" U ILL <br /> COMMENTS: pAYM <br /> RECEIVED <br /> MAI3QUIN COU <br /> 1 2012 <br /> SANERpONNI <br /> 7 <br /> ACCEPTED BY: __. EMPLOYEES: DATE: <br /> ASSIGNEDTO: V� C� EMPLOYEE DATE: <br /> Date Service Completed if kralady completed): EERUE60DE: S( PI E: 23Q <br /> Fee Amount: o J Amount paid 3 7 Payment Dateve <br /> Payment Type I invoice# Check# Received By: <br /> o101� <br />