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May 1214 09:16a Reliable Petroleum <br />0 <br />2098458953 p.3 <br />0 <br />SAN JOAQUIN COUNTY ENVIRONM1ENTAL HEALTH DEPARTMENT <br />.SERVICE REQUEST <br />Type of Business or Property <br />'�'_ <br />FACILITY ID # <br />SERVICE REQUEST # <br />LPo <br />PHONED _ EXT. <br />HOME Ot'IMIAIUNGADDRESS <br />`��—' � , e � +_ � <br />jE j� <br />REC EIVEp <br />u <br />6ci �3 i <br />OWNER I OPERATOR y <br />�'� �' <br />_1 <br />P%tAA A r <br />lU. <br />CHECK N BILLING ADADURESs ❑ <br />FACILITY NAME <br />ENVIRONM <br />SITE ADDRESS <br />j✓�' <br />� <br />HEALTH DFPA <br />(�Y�jl �'�} <br />) <br />q 5 .;. <br />2-c- 7 © <br />DATE: 9)13//0 <br />ASSIGNED TO:LLQ , <br />EMPLOYEEM <br />GG'J I <br />ZIP Ccde <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />] <br />SERVICECOQE: I G' <br />P f E: <br />Fee Amount: 5 —� <br />Street Number <br />Stmot NIM <br />S <br />CITY <br />Invoice <br />STATE ZIP <br />�T ` <br />PHONE 1 - <br />> <br />APN# <br />LAND USEAPPLICATIONi: <br />PHONE Ekr- <br />BOS DISTRICT <br />LOCATION CODE <br />( > <br />� <br />v o- <br />4 c <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR _ �} `I ,4+ - <br />CNECKNBILLING ADIRiESS <br />BUSINESS NAME <br />PHONED _ EXT. <br />HOME Ot'IMIAIUNGADDRESS <br />`��—' � , e � +_ � <br />jE j� <br />REC EIVEp <br />tAx#�y_�� <br />�jS �� <br />i <br />CITY in � LJA L_ <br />STATE �1P <br />[G' <br />BILLING e+ lCKN0WLEDGEME'+IT: 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 la <br />APPLICANT'S SIGNATURE: ' �wslvt�DATE: <br />PROPERTY JBU, IN65SOWNER❑ ERATOR I NUNWER ❑ OTIIERAUTrioRIZEDAGENTFr( d a (r <br />If .4PPLICAA+T is not tate BiLLiNG PARTY ,proof of authorization to sign is required Ti tie <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 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 OF SERVICE REQUESTED: CCM S (,�,� #" <br />PA <br />COMMENTS: <br />REC EIVEp <br />MAY <br />Y 13 2014 <br />MAY I 2 <br />ENVIRONM <br />HEALTH DFPA <br />ACCEPTED BY: 'V'. 7 <br />EMPLOYEE#- <br />2-c- 7 © <br />DATE: 9)13//0 <br />ASSIGNED TO:LLQ , <br />EMPLOYEEM <br />GG'J I <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICECOQE: I G' <br />P f E: <br />Fee Amount: 5 —� <br />Amount PaIdV375.6D <br />Payment Date <br />S <br />Payment Type 1'S� <br />Invoice <br />Check # <br />�T ` <br />Recei ed ray: <br />EHD 48-02-025 SR FORM (Golden Rad) <br />REVISED 1111712003 <br />ENTAL <br />;:NT <br />