Laserfiche WebLink
May 19 08 03:01p RELIABLE PETROLEUM SERVIC 2098458953 p.3 <br /> • • <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#00 <br /> Id <br /> OWNERIOPERATOR Ja1r)c� / J <br /> L i � j CHECK If BILLING ADDRESS <br /> FACILITY NAME S <br /> SITE ADDRESS <br /> Street Number I Direction ! ! Street Name f Cit Y Zh3 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#11 EXT* APN# LAND USE APPLICATIDN# <br /> PHONE#2 Exr. BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Err.eEf�� .Gtl l Vi T c '96 t/ 9V S_ s & <br /> HomE or MAILING ADDRESS FAX# <br /> d► 9r,3JI&i idd 9) ?I1 s7- <br /> CITY <br /> -CITY O coA.CJA-e_ STATE CA_ Zip <br /> BILLING ACKNOWLEDGEMENT: I, 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: (: i1.1Z ��( - DATE: <br /> PROPERTY I BUSINM OWN ERC OPERATOR I? ANAGER ❑ OTHER AUTHORIZED AGENT® ( <br /> If APPLICANT IS not the BILLING PARTY',proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 environmentalisite assessment <br /> information to the SAN JOAQUIN 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 OFSERVICE REQUESTED: ep lace L e&k-r_)e_+e p r (j� yam'? 'a9 �TGt 1J� �v��-- j�� <br /> COMMENTS: ` 0.0 41 Nl�ti �.t��IT V 1 �C�l� !- IV— <br /> X/ EISSW�' ). - L <br /> MW 19 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: z rTTATE: <br /> ASSIGNED TO: Q reA <br /> S EMPLOYEE#: q(0 DATE: <br /> Date Service Completed (if already completed): SeRVICE CODE: P 1 E <br /> Fee Amount: Amount Paid Paymen Date <br /> 6 <br /> Payment Type Invoice# Check# - _ - Received By: <br /> Con �/hr�or7� aa33a5 <br /> EH 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />