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Aug 25 08 09;17a Reliable Petroleum 209-845-8953 p.8 <br />SAN JOAQUINPUNTY ENVIRONMENTAL HEALTHIPPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />�� <br />FACILITYD#I SERVICE REQUEST # <br />CHECK if BILLING ADDRESS C <br />OWNER /OPERATOR <br />V f� <br />� <br />CHECK If BILLING ADDRESS <br />FACILITY NAME IV� 6 P �0 <br />-- <br /># <br />c vy } <br />SITE ADDRESS t,l („� I✓J <br />tt <br />CITY oo y- &ot -e– STATE <br />� <br />ZIP S / <br />2 <br />P I E�-70 <br />Fee Amount: �� <br />Street Number <br />Oirection <br />Street Name <br />Payment Type <br />Cit <br />2i Code <br />HOME or MAILING ADDRESS (H Different from Site Address} <br />Street Number <br />Street Name <br />CITY <br />STATE zip <br />PHONE #1 EX r• <br />ft q)a34--1� S� <br />APN 0 <br />LAND USE APPLICATION# <br />PHONE 92 ExT. <br />(M) (.0 Ll _ 3 DCS <br />BOS DISTRICT <br />LocAnON CODE <br />11 <br />CONTRACTOR / SERVICE REQUESTOR <br />REgUESTOR ?—Ober--``- <br />�l4 `� <br />vT��.'�t ' ``T 1JCk.Y�Y�.%C�,Y- <br />q^'�o� 8 <br />CHECK if BILLING ADDRESS C <br />BUSINESS NAME . <br />PHONE# <br />9, <br />EXT.p-(fXkci-Ue <br />HOME Or MAILING ADDRESSFAX <br />5� t>ra t1�t'ti+2 rvti,, 5$_ <br /># <br />c vy } <br />L/S -S <br />CITY oo y- &ot -e– STATE <br />C..- <br />ZIP S / <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMt nTAL HEALTEi DEPARTMENT hourly charges associated with this project <br />or activity will. be bi€Ied to me or my business as identified on this form. <br />I also certify that T have prepared this aDolication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Stan.4 ds, S ATE and FEDERAL laws. <br />APPLICANT'S SIGNATURES I, DATE: I3/ C9:5k,9 <br />PROPERTY/BUSINESS OWNER[] OPLRATORINIANAGER ❑ CTI ERAvTHORIZEDA.GENTX—I�a�j '/-� <br />If,4PPLIC.9IVT is not the Ell_! 1AG PAR71'. proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the propert ��,� the <br />above site address, hereby authorize the release of any and all results, geotechnical data an&or environmental,si t i t3 <br />information to the SAN JOAQUIN COUNTY E1tivIR0NA1IFNTAI, HEALTH DEPARTMENT as soon as it is available and at tllte, Mme <br />provided to me or my representative. �J ! <br />TYPE OF SERVICEREQUESrED: �''4-,C.`i U,-) 7-L-5 -�. ,50 void - ��c Pl <br />q^'�o� 8 <br />COMMENTS: � Placed T� �' -C C� e - P l�' •tJU0'4' doe 1 c �7 4 L� e "` TN M O <N <br />,, r <br />. P��{(hCJta� ACU --t�S4-ecl SPncc;n� T <br />E-ect-t CG...�. o teaA56o <br />i € v-) P' ov1 I y� i �1� �} t �tC'� I �•x {n }C.,`� -0 , <br />D tit- 1C�1 bv� S i 0. �FLL ��Yte �tCn�S 3'P"f-oi•-Q <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE- <br />ASs[GNEDTO: A/r rp <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if already completed}: <br />SERVICE CODE: <br />2 <br />P I E�-70 <br />Fee Amount: �� <br />Amount Paid 315 <br />Payment Date <br />Gi aJ v j ' <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 " " ' g SR FORM (golden Rad) <br />REVISED 11/17/2003 <br />