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Jul 01 10 11:54a Reliable Petroleu� 2005-8953 P•2 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID A SERVICE REQUEST # <br />212-7 SW_ 0 0 & 03 ?) <br />OWNER 1 OPERATOR (�� u i y 4n CHECK if BILLING ADORess <br />FACILITY NAILW 0- t 21� U C% �C> �� (A I F"`�' <br />SITE ADDRESS 3 v 2 o 1�� �' moi? F�'� �' - ` 1!J ( ��n ! s !% <br />-/ Street Number Dlrectio Street Nw C r Ca <br />NONE or Ma1LING AC.)m= 1DYINOrSI Address) <br />Street Number <br />CITY �� � STATE street U.— <br />PHONE 01 EXT. APN LAND USE APPurA <br />*0q) --*-'/ to t�o_3a <br />PHONER ExT• BOS DISTRICT LOCATION CODE <br />I I -A 2 �-- <br />CONTRACTOR / SERVICE REQ U JES'101c. <br />REQUESTOR f) _ j ) Y )� .d �/ CHECK it BILLING AMRESSU. <br />_ EST. <br />BUSINESS NAME ��(Q:k�1 e �e�t�� CL4I J 21�1�1 Les �C - A r% d <br />HOME or MAILING ADDRESS ,� z �-1�01� � - "70 `l) EV 5` - 9 �S-3 <br />CITY STATE (2 A- 'Zip <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or auinertzeu ugrut V. aauav, <br />acknowledge that all site andior project specific ENVIRONMENTAL HEALTFI DEI'ARTh1ENT hpW�ssociated with this project <br />or activity will be billed to me or my business as identified on this form. RECEIVED <br />I also certify that I have prepared this application and that the work to be performed will b0iftlle in arq�pce with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL IaWS. V �L LLVV','t++ <br />f SAN JOAQUIN U <br />APPLICANT'S SIG NATURE:�`�'�'�"t'� <br />HEALTH�t <br />PROPERTY/ BUSINESSOWNFR❑ OPERATORI MANAGER ❑ O'rHERAUTIIoRIZEn AGENT 61 SGL <br />If APPLICAJVT is not the BILLING PARTY, proof of authoriyation to sigh 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 environmentalisite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DGPARTMEN7 as soon as it is available and at the same time it is <br />provided tome or my representative, (,�S t / /i r— �-+�'4 1 ✓� is <br />-16 TYPE OF SERVIGE REQUESTED: l U�t/CJ�- �l i ,�% L f D 9 d u1 l'1 u fZ t 1(} ��� L <br />-n . a,�, _0 S l e GUJ?-4 <br />:� i11-�& 0-'L +7 a <br />t�/u /�,►', <br />�ryyP�t <br />�!'/� ,a L"e'l Oki <br />(I, <br />tt & .. i� .0PO2A00c <br />ACCEPTED BY: © (_f U£ ( EMPLDYEE#: D DATE: <br />ASSIGNIED TO: `^/ C� N EMPLOYEE#: T a DATE: �! <br />Date Service Compteted cif already completed): <br />SERVICE CODE: RS' <br />P l E: (� <br />Fee Amount: $+i 7 S a <br />Amount Paid 5 <br />Payment Date 0 <br />Payment Type ✓ <br />Invoice # <br />Check # X if <br />Receiv By: <br />EH D 4$-02-025 <br />REVISED 11117/2003 <br />SR FORM (Golden Rod) <br />WIR <br />0 <br />3 o <br />