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May 12 14 09:17a Reliable Petroleum <br />0 <br />2098458953 P.9 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NT9xilysTEW, <br />Type of Business or Property <br />FACILITYG <br />MAY T <br />SERVICE REQUEST 9 <br />ENVIROPI <br />HEALTH DE <br />Accarim BY; <br />EMPLOYEE <br />OWNERIOPERATOR <br />ASSIGNED TO: <br />EMPLOYEE <br />L DATE: <br />Date Service Completed (if already Completed): <br />FAcamNAME <br />PIE: <br />SITE ADDRESS <br />V-7 <br />Amount Paid <br />Payrrrent Date <br />tre <br />--aetNumbor <br />0 <br />imt-Imn <br />ga Name <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />CITY <br />t mbar <br />N <br />STAIR zip <br />PHONE I <br />) 7LF <br />APN <br />1 <br />LAND USE APPUCAMN 0 <br />PHONE Ext. <br />---- <br />WS DISTRICT LOCATION CODE <br />CONT-RACTOR SFRVICE REQESTOR <br />REouEsToRfl <br />— t�rxrn � clr+-- CHEM if M "LNG ADDRESS <br />ausl Ess NANIE PHONE Ext. <br />HOME or MAiuNG ADDRESS of <br />FAX III <br />STATE rA— zip <br />BILI,ffi—G ACKN wl,FRfi&M—ENT. 1, the undersigned property or businesser, operator or authorized agent of same, <br />acknowledge that all site wdlot project specific, ENVIRONMENTAL HEALTHDEPARTOMWERNT 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 wRI be done in accordance with al I SAN JOAQUIN <br />COLINTY Ordinance Codes, Standards, STATE and FEDERAL la <br />APPILJCANT'S SIGNATU RE: r- 'W" r 13"w <br />Wd— DATE: <br />Lw� <br />PROMTY I Bu- LN&qs 0wKF R M 6ftX4TORJ MANAGER 0 0TnxR AuTHoRmED AG,,,)ff C.W fy f, for- <br />1f,4PPL1CAxT is not the B1LLJ!1;G PXR7Y PFOOf Of authori60don to sign is required il—We <br />AUTR0RgA]3ON TO RFL CAS—E INFORMATI[Q.N: When applicable, 1, the owner or operator of the pr <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or cnvironm <br />information to the SAN joAQLnN COUNTY ENVIRONWNITAL HEAL-rH DEPARTMENT as Soon as it is available and NE assIVED <br />provided to me or my representative. <br />TYPE OF SER=E REauESTED: <br />COI CI OsAalr-t- <br />MAY T <br />ENVIROPI <br />HEALTH DE <br />Accarim BY; <br />EMPLOYEE <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE <br />L DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />Amount Paid <br />Payrrrent Date <br />1125 <br />REV <br />REVISED 11117/2003 SR FORM (Golden Rod) <br />43M <br />