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Mar 19 13 12:23p Reliable PetroleumA 209-845-8953 p.29 <br />AN JOAQLIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />type at Business ar Prperty FACILITY ID # <br />SERVICE <br />GREQt1EST # <br />OWNER/ OPERATOR <br />CHECK If BILLING ADDRESS CJ <br />FACILITY NAW f <br />Grp wV3 evcl A e'' <br />$ITE ADDRESS . i 0 rj - t <br /><tiUny C�t,t-:b ti3t�� �7GiC�y-i gS.aG7`/ <br />10 <br />Street ober Dlrec an Street'9 <br />HOME OT MAILING A,DDRES llf Different from Site Address} city r � z� Caae <br />CITY street Number Str et N ma <br />✓T() (mac, n STATE � zip q Li <br />PHgNE #1 r _ Exr. APN # <br />(, 0 q) 1.I2 LIP { —L LAND USE APPLICATION # <br />PHONE A 1 EXT. <br />{ } SOS DISTRICT LOCATION CODE <br />REQUESTOR <br />CONTRACTOR f SERVICE REQUESTOR <br />BUSINESS NAME <br />PHONE Ex-. <br />HOME Or&WL.I1IG ADDR S �~ � <br />p I143v f EuI'"5E'st� FAx <br />CITY Srare <br />r LP fl' -.- <br />acknowledge that all sit <br />or activity will be billed <br />I also certify that I have <br />COUNI-Y Ordinance Cab <br />APPLICANT'S SIGN.4 <br />PROPERTY / BUSINESS UlYN, <br />If.9PPL1c.•t <br />above site address, h <br />information to the S.4N <br />provided to me or my n <br />TYPE dF SERVIrE REQUEST <br />COMMENTS: <br />ACCEPTED BY: <br />ASSIGNED TO: <br />Date Service Completed <br />Fee Amount: <br />Payrnent Type A Al <br />EHD 48-02-025 <br />REVISED 11!17/2003 <br />D(;EMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />Ind./or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />me or my business as identified on this form, <br />epared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />, Srandards, STATE and FEDERAL laws. <br />URE - <br />'°'e4 '' BATE: f . <br />to OPERA'roRIMANAGER 0 OTHER AUTnoRIzEDAGMT <br />r is not the ALL -"Vo Pa Tv, proof of QutirorizXion to sign is required Tl tl e <br />RELEASE INFOWN-1ATION: When applicable, I, the owner or operator of the property located at the <br />y authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />QUIN COUNTY ENVIRONMENTAL HEALTI-i DFPARTMCNT as soon as it is available and at the sante time it is <br />sentative. <br />-P-'M0 V -U L -Lr> 9 <br />99 LA-Z>'Woo <br />EMPLOYEE #: <br />i4 e- K L EMPLOYEE #; <br />already completed): SERVICE CODE; <br />,3' =Amount 7 v Payment Date <br />invoice # Check # <br />DATE: ��/ <br />P I E. z-3 <br />� a© <br />Received v: 1- D <br />SR FORM (Golden Rod) <br />