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Auq 07 12 03:08p Reliable Petrole 209-845-8953 p.3 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Pn perty FACILITY ID#i SERVICE REQUEST# <br /> GID r— - -F-1� o o Z <br /> OWNER 1 OPERATOR <br /> CHECK If BILLING ADDRESS Cl <br /> FACJLITYNIAME <br /> SrrEADDRES8 F ,{ �t/1Ttvk <br /> V6i ,+ J�3"? <br /> Struat umber I)iraction Street Na � �Ci 2i Co <br /> HOME or MAILING ADDRES 5 (If Different from Site Address) <br /> Street Number Strout <br /> CITY STATE ZIP <br /> PHONE'#1 ExT• APN# LAND USE APPuCATION <br /> PHOm E#2 EX-1. BOS DISTRICT LOCATION CODE <br /> I I <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQU ESTOiZ <br /> r-# 6;a,(,xhae, <br /> — CHECK if BILLING ADDRESS <br /> BEISINESS NAME j Ci eTJ le .7� �' -.}-►I 1�., . PHONI r. <br /> Ex <br /> HomE or MAILING AoDR ss F,34 1) - eel 5-3 <br /> CITY STATE ZIP 9-j5- <br /> BILxLING ACKNO31 Ell EMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Si a 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 hav prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIs <br /> COMTY Ordinance Coi res,Standards,STATE and FEDERAWaws, <br /> APPLICANT'S SIGN TUBE: T"J"d—� <br /> PROPERTY/BLSINESSO10Y 'ER❑ OPERATORI-MANAGEREl OTHERAu-rHORIZEDACaNTI�r <br /> T �r <br /> if APPLt AAYT is not the it L n•'.G PARTY,proof of authorization to sign is required LLIL TR t to�',,.• <br /> RUTH RIZATION RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, be eby authorize the release of any and all results, geotechnical data and/or environmentaVsite assessment <br /> information to the SAN OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is <br /> provided to me or my re msentative. <br /> TYPE OF SERVICE REQUEST r ..C.! W,E IN <br /> COMMENTS: V E D <br /> AUG -- 3 2012 <br /> SAN JOAQU N COUNTY <br /> E.NYIRON 0EN7AL <br /> HFALT}i DE'. ARTME.NT <br /> ACCEPTED BY: EMPLOYEE#; DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (it already completed): SEWW CODE: PIE: <br /> Fee Amount S,�' Amount Paid 43-7 51, 0 l0payment Date l Z <br /> Payment Type Invoice;* ,Fh 1�+Chheeck# Received By: <br /> EHD 48-02-025 W"�1� �` D-- �� v `� SR FORM(Golden Rodf <br /> REVISED 11117/2003 U <br />