Laserfiche WebLink
Mar 30 12 02:26p Reliable PetroleumA 209-845-8953 p.3 <br /> AN JOAQU 7OUNTY ENVIRONMENTAL HEAL'_ )EPARTMENT <br /> ' SERVICE REQUEST <br /> Type of Business or Pro erfy FACILITY IQ# <br /> G�F r� SERVICE REQUEST <br /> OWNER(OPERATOR # <br /> T � /`c'& k q(- -7J'AA C <br /> r <br /> CHECK ifBILUNi G,Q� ppAESs❑ <br /> FACILITY NAME to o4� -e� —A�cc <br /> SITE ADDRESS _LJ_0 <br /> S• .1�a►17 S J r�� c �5 3, <br /> Street Nu ber Direction t eetet Name <br /> HOME or MAILING ADDRESS If Different from Site Address) Q ZI code <br /> CITY Street Number Street Neme <br /> STATE zip <br /> PHONE11 ExT. APN# <br /> LAND USE APPLICATION iN <br /> PHONE#2 19 I Exr. <br /> SOS DISTRICT LOCATION CODE <br /> REQUESTOR CONTRACTOR !SERVICE REQUESTOR <br /> CHECK if BILLING ADDRESSID <br /> BUSINESS NAME' PHONE# Exr. <br /> � 1 T� U �•/5/� LAS �yl L' .3G� ��/S- �5 g",(� <br /> HONfE or MmuNG ADDRES Flue# <br /> 3� �rSesl�cr-c ' , <br /> �!"�� <br /> STATE /� /� LP <br /> `F1 �S3CF' � <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 FN'V'1RONMENTAL HEALTH DEPARTMEN'r hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> f 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 FEDERAL laws. <br /> APPLICANT'S SIGNA IRE: =vim,: ... �. _.C,�=�' <br /> DATE:_ Q3/3D//Z <br /> PROPERTY;BUSINESS OwNE ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGCNT EJ <br /> I <br /> ffA,PPLic,4,A F is not the 9fLL1,VG PARTYProof of authorization to sign is required Time <br /> AUTHORIZATION TO ZELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, herel:, authorize the release of any and all results, geotechnical data and/or environmentalisite assessment <br /> information to the SAN JO QUIN COUNIY ENVIRONMENTAL HEALTH DEPARTMEN?as soon as it is availab?e �nrj ar the game time it is <br /> provided to me or my rept entative. <br /> TYPE OF SERVICE REQUESTED, 0 l.. T/9 SL-( i--p f4-56 t-- 7y L/3 go•-3 Z 3 <br /> COMMENTS: <br /> S 2(e1SG�� �t�2 ✓�rf� pAYME <br /> J RECEIVED <br /> • APR 0 2 2012 <br /> SAN,toAQUIK CCUN7y <br /> ENVIRCHMEKTAL <br /> �IEA�TH pA.RTp7EM-. <br /> ACCEPTED BY: f �- EMPLOYEE#: DATE: <br /> -- <br /> ASSIGNED TO: �I t EMPLOYEE#: ) DATE: <br /> Date Service Completed (� already completed): SERVICE CODE: j PIE: <br /> 1-3c). <br /> Fee Amount: Amount Paid 37 S711� V Payment Date 2- <br /> Payment <br /> Payment TYAe I Invoice# Check# Received By: Z� <br /> EH 48-02-025 ' I q7D — <br /> REWSED 11!17!2003 SR FORM(Golders Rod? <br />