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Jul 01T10.11:32a Reliable Petrol e 2 -845-8953 p.36 <br />SAN JOAQUIN COUNTY ENVIRON -'MENTAL HEALTH PAR'iN1ENT ���� 11C, <br />SERVICE REQUEST <br />FACILITY 11] # ERVICE REQUEST # , <br />Type of Business or Property-F�"��j"`' <br />t <br />OWNER OPERATOR��L` L <br />FAciury NAME Wo- t f -r Lo C; 70 o C� <br />SITE ADDRESS �� <br />Street Number 1 Direction Stree <br />HOME or MAILING ADDRESS (If Different from its Address) <br />CITY <br />PHONE #1 E APN # <br />PHONE #2 ExT. <br />CHECK if BILUN_ G aooREss 10k <br />STATE Zip <br />LAND USE APPLICATION * <br />BOS DISTRICT <br />`513 0 <br />t_oCATiON CODE <br />CONTRACTOR /SERVICE REQUES`i'UK <br />REGtUE$T'OR A �.- `_ i ,� } �a f `� �n �C%� CHECK BILLING ADDRESStJ.. <br />cJ C�1 "r l..C.J%� j pf ` ii tt 1` EXT. <br />BUSINESS NA(N£ ie <br />} l o,19 <br />1 e Pe✓ f ir6 k -Irl. V" l� L� I Cie S <br />HOME Or MAIUNG ADD TRESS �5 -21 IrGt f'7 {,� (1' J irUN 5-� - q <br />CITY ©q 1! . d'0—t-.e STATE C A- zip f!5- 3 4,1- <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 ENVIRONNIENTAL HEALTi-i 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 JOAQUI'I <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:h' Det rE: } 1 C) -� <br />PROPERTY/ BUSINESS OWNERE3 OPERATORY MANAGER 13OTtlERAuTHORizEDiAGExT ® (�Y1�i(t:� S..Ci 4/ <br />IfAPPLICANT is not the BILLIYG P.1RTY, proof of audivrizaltion to sign is required 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 HEALTpi DEP,ARTVIEN7' as soon as it is available and at the same time itis <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED:K�iIJc�(/CVJ�h�a 'uVJ /4S /'it LO <br />rtrl,.(1LLDl�n <br />Ap l 'r"'C G•d 7 <br />ctY�w ��e.-to �w`G•-�.� I� rlli Pu}� C <br />ACCEPTED BY: EMPLOYEE#: <br />DATE: <br />ASSIGNED TO: EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Fee Amount: <br />Amount Paid Payment Date <br />Payment Type invoice # GneCK OF <br />Received By: <br />SR FORM (Golden Rod) <br />EHD 48-02-025 <br />REVISED 1111712003 <br />eav <br />