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Mar 31 09 11:29a Reliable PetroleumA 209-845-8953 p.45 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property GFACILITY ID# SERVICE REQUEST# <br /> � � <br /> OWNER/OPERATOR rt e— I S h (nJ <br /> 1� CHECK It BILLING ADDRESS <br /> FAciuTY NAME (l�-'P MA�--T r� j <br /> SITE ADDRESS�5 r l'1 5 S . p0., ���So p�s <br /> Street Nv mbar DIrectlan Street Na me Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Sheet Name <br /> CITY STATE ZIP <br /> PHONE#1 Ev. APN# LAND USE APPLICATION$ <br /> (aoq ) F 3 b-r19' <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR1�/1 1 <br /> K e 1/l.p r� <br /> BUSINESS NAME, CHECK it BI LI.ING ADDRESS <br /> \�C.J� PHOFE <br /> E-. <br /> HOME or MAILING ADDRESS] l,.a vi I t�0 Srp>� �� FAX# <br /> o �U ) I S g <br /> CITY OCL /��( '� STATE C,4 ZIP <br /> BILLING ACKNOtWLEDGEtiIENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that ail 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, TATE and FEDER-AL laws. <br /> APPLICANT'S SIGNATURE: DATE: C� i <br /> PROPERTY/BUSINESS OWNFR❑ OPERATOR/NIAN.AGER ❑ OTHER AUTHORIZED AGENT L} <br /> ff APP._ICIINr is not the B/LLf�yc P.41tn-, proof of authorizafion to sign is required Tirl <br /> AUTHORIZATION TO RELEASE INFORNIATION: When appi[cable, I. 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 and/or environmental/site assessment <br /> information to the SAN JOAQUEN 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 /> COMM,ENFS: <br /> (_�fxT oid- 3tylsor on Sq n <br /> f♦-I LL r <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE. <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />