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Nov 30 10 05:24p Reliable Petrol A 2845-8953 p.3 <br /> AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Pro C FACLITY ID# SERVICE REQUEST# <br /> Y- 6-7 8 <br /> OWNERI OPERATOR / f/_ ///�� / '- <br /> Z(/'` l �f ba b I& ` CHECK If BILLING ADDRESS C� <br /> FAciury NAME <br /> SITEADDRESS 1 t�SDC) QI"a!G Y] )-V L Q f 1)I�fJ� /Y533D <br /> Street N bet Direction Street Name I city2i Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ,ZIP <br /> PH'ONE#1 Exr. APNa LAND USE APPucATIoN# <br /> (91)9 ) q03-3?S7 <br /> PHONED EXT. SOS DISTRICT LoCAnoN CODE <br /> ( 1 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> A)REQUESTOR �J� <br /> 6 Ci.rY1 CHECK if BILLING ADDRESS <br /> BusiNess NAND Q �1 �� Q <br /> 1 s—C�pst r Ern. <br /> ( <br /> HOME Or MAILING ADDRE !�n� LLQ�.��] �� p Fes$ <br /> tcTY � t STATE C f- ZIP 9� / <br /> BILLING ACIKNOWL DGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acimowledge that all site andior project specific ErvIRON[v ENTAL 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 Code,Standards, STATE and FEDERAL ws. <br /> APPLICANT'S SIGNATURE 0 U (, DATE: <br /> e: <br /> / <br /> PROPERTYIBUSI nSSS0V^k RO U ERATORINIANAGk:R ❑ OTIjEaAUTHORIZEDAGiKN-f <br /> If APPLICA 'T is nOt the BIL LAG PARTY.proof of authorization to sigh is regnired 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMCNT as soon as it is available and at the same time it is <br /> provided to me or my rept sentative. /1 - n —A ,Q (•7— <br /> TYPESERVICE REQUESTED: <br /> COMMENEN TS; J�'I. C -r2 h/1 <br /> t -7 12L-22000--, -��n T <br /> J- I <br /> RECEIVED <br /> DEC -2 010 <br /> UiNu�N,-Y <br /> iRONM E 4TAL <br /> ^ HEALTH DEP THEW <br /> ACCEPTED BY: O �.,- V E 1 12-A EMPLOYEE#: Q 3 DATE: t Z �110 <br /> ASSIGNED TO: EMPLOYEE#: y� DATE: ( 2. <br /> Date Service Completed if already completed): SERVICE CODE; . PIE: �D <br /> Fee Amount: 3 G Amount Paid 'P 3 (o_ p Payment late �! <br /> Payment Type V Invoice# Check# v ! <br /> V,5 Received By: <br /> EHD 48-02-025 <br /> REVISED 11;1712003 VISA SR FORM(Golden Rod) <br /> Co1�3 G- <br />