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Aug 17 09 10:14a Reliable PetroleumA 20M45-8953 p.3 <br /> SAN JOAQtOCOUNTY ENVIRONMENTAL HEALTITAEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 75'7 Si'L ooSd-C7/ <br /> OWNERI OPERATOR J('�� t p1 / y� Int <br /> � C- ^ `V�S�!r� �r 1' S / L L CHECK if BILLING ADDRESS <br /> FACILITY NAME Q��I q /l q I /I /M PM <br /> SITEADDRESS / 1 l., lJtt /? /1 <br /> �1 �55" S }�i� h9 Sjocicfic� /S- <br /> Street Number tion J wOSweet Nam? C Z Cotla <br /> HOME of MAILING ADDRESS (If Differimt from Site Address) <br /> Street Number smet Name <br /> CITY STATE LP <br /> PHONE#1 LAND USE APPLICATION# <br /> tool ] 9t15-aL13 $ l7 �- 2leo -S'I <br /> PHONIER ErT BOS DISTRICT LOCATIO CODE <br /> ( I Z <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR c-r fJC.r'I-L h 6 j�-�— CHECK if BILLING ADDRESS <br /> BUSINEssIMPAE (J�'1���1.p nf�l y-7� (}�p- <br /> 9 lc Pef olecim SLvrv,'6CS �(1 PNDta:f y^�yS=6,rn�� U /iE <br /> HOME Or MAILRJG ADDRESS Sz 1 FAx It <br /> t')&9 i U LI J 9S�(3. <br /> CITY STATE C,4-- hP 3&,/ <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me 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 JOAQuIN <br /> COUNTY Ordinance Codes,Standards,STATE and FERAL laws. p <br /> APPLICANT'S SIGNATURE: I L) DATE: 0 I� <br /> PROPERTY/BUSINESS O\SNER❑ MNAGER OTHERAI. AGENT <br /> OPERATOR ❑ ® <br /> IfAPPLICt.NT iS not the BILLING PARTY proof of authorizatiaa to sign is required TitleT <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 andlor environmental.'site assessment <br /> information to the SAN]OAQLIN COUNTY"ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: `r L RECEIVED <br /> AUG 17 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: C)L-t ✓F— ti1 n EMPLOYEE 4: 6) L DATE: ell-710 <br /> ASSIGNED TO: V c -J FI/TL(F37 <br /> EMPLOYEE#: q / <br /> C� '7 DATE: �- Int 0 <br /> Date Service Completed (if already completed): SERVICE CODE: / q I P I E: 2 <br /> Fee Amount 3 s J-b Amount Paid y, 5 — Payment Date .� <br /> Payment Typo tt`' Invoice# Gback,# 3 3 3 1 Received By: <br /> e <br /> EH D SR FORM(Golden RocQ <br /> REVISEDSED 1111 71/17/2003 <br />