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J 04:53p Reliable PetroleumA 209-845-8953 p.3 <br /> 0 <br /> SAN JOAQUII COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or property FACILITY 1D# <br /> G- —i <br /> '1 F <br /> �O O `��� SERVICECREQUEST�j# <br /> OWNER/OPERATOR �'� <br /> BILLING ADDRESSL...I <br /> FACILITY NAME CHECKif� � � � � � n 1 <br /> SITE ADDRESS1 5 LA,/, <br /> Street Number Tri <br /> Direction �Street Ne 93 <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ci zi C de <br /> CITY StreeiNwnber Ste& Na e <br /> STATE ZIP <br /> PHONE#13S FX-r APN# <br /> (meq ) ;3 9 _- *� LAND USEAPPLICA710N# <br /> PHONE#2 <br /> (`J 1 0 ) LIP-1 L1 — 530, BOS DISTRICT LOCATION CODE <br /> F2EQUESrOR <br /> CONTRACTOR/SERVICE REQUESTOR <br /> Rl.'1� e'r+ �� t CHECK if BILLING ADDRESS, <br /> BUSINESS NAME Q Q l a- II0PHONE# <br /> HOME Or lHA1LING ADDRESS � �, � <br /> ` Z� �I cc4j I►t. srs7r c. (A41) PY F9s� 3 <br /> CITY 0 Ll IL&CL.-t`c- STATE CA ZP 95"3 �"/ <br /> BILLING ACVNOWLEDGEMENT.- L the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONv1ENTAL HEAL'nI DEPARTv;E2NT 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, ATE and FEDERAL laws. <br /> ws. <br /> APPLICANT'S SIGNATURE: JA L `' -f_G"CX I `A r DATE_: <br /> PROPERTY/Bust-wss OWNER❑ OPERATOR I i4iA NAGER ❑ OTHER AUTHORIZED AGENT IEl <br /> lfAPPL'CANT is not t/ze BIL-LINC PARTY Proof of eathorizariatt to sign is requiter! Title <br /> AUTHORIZATION TO RELEASE Tl\'FORMATION: When applicable, 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 JOAQUIN CQUNTY ENVIRONMENTAL HEALTH DEPAR nm-ENT 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: `1 0" V/vic G C�q/ b SCJ O <br /> COMMENTS: l _ <br /> D <br /> �l C2 00 JUN 1 1 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: L <br /> v <br /> Date Service ComDATE: <br /> pleted {if already comp ted): SERVICE CODE <br /> g« Z <br /> Fee Amount: I Amount Paid ` 5 Payment Date `t 0 <br /> Payment Type - �� s Invoice# @heck# p g g Z Received By, <br /> tr- <br /> EFID 48-02-025 <br /> REVISED 1111712003 SR FORM(Golden Rod) <br />