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SAN JOAQU COUNTY ENVIRONMENTAL HEALTAEPARTMENT SERVICE REQUEST Type of Business or Property &asoline Station / SERVICE REQUESTOR FACILITY ID # o O0 Ll 5LI `7 SERVICE REQUEST # OWNER / OPERATOR OHSVXdN Fr15 >UGTS Gd• CHECK if BILLING ADDRESS 2Q5 FACILITY NAME * 2-0- 1505 BUSINESS NAME. RHL Dcstgr� �fbuP In. SITE ADDRESS1GI�yQ Street Number W, Direction EXT' 313 • �l'�D�d _ (D} StTc'=-+ Street Name _� Drive Suite Trac i �i537Co Zi Code HOME or MAILING ADDRESS (if Different from Site Address) Street Number Street Name CITY ZIP GI9.55 STATE ZIP PHONE #1 EXT• ( ) APN # SERVICE CODE: LAND USE APPLICATION # PHONE #2 EXT. Amount Paid Z '� - C90 Payment Date BOS DISTRICT LOCATION CODE BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator ol(authorized agent o same acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated withhis project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: -7 -Z1- d+ PROPERTY/ BUSINESS OWNER❑OPERAT�i / NUAGER ❑ OTHER AUTHORIZED AGENT U Me4+ Man OCC If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. . AI: V11 TYPE OF SERVICE REQUESTED: Repair / SERVICE REQUESTOR COMMENTS: Plan Chcek 'for &Pill REQUESTOR A24z C�ianind ?roj. Mgr+ CHECK if BILLING ADDRESS BUSINESS NAME. RHL Dcstgr� �fbuP In. PHONE# 925 EXT' 313 • �l'�D�d _ (D} _.._r. HOME or MAILING ADDRESS 134b Arnold _� Drive Suite ACCEPTED BY: V ��",n I'n FAX# (925) 313 • CITY Hartiviloe r, I ASSIGNED TO: S. STATE CA ZIP GI9.55 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator ol(authorized agent o same acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated withhis project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: -7 -Z1- d+ PROPERTY/ BUSINESS OWNER❑OPERAT�i / NUAGER ❑ OTHER AUTHORIZED AGENT U Me4+ Man OCC If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. . AI: V11 TYPE OF SERVICE REQUESTED: Repair 12etrof;t Ptah Ghe:Gk PPS JEwE`J COMMENTS: Plan Chcek 'for &Pill C.06"aihment replace-In4 t. 204k 30- SPN 3� RO A00 PSM�N� NIN- OLSN �EpA ACCEPTED BY: V ��",n I'n EMPLOYEE #: 3 (, DATE: -71 r, I ASSIGNED TO: S. EMPLOYEE #: 3 S[ O DATE: -7 2l7 o`1 Date Service Completed (if already completed): SERVICE CODE: PIE: Z 3� Fee Amount: Z'1,ij , o p Amount Paid Z '� - C90 Payment Date -7146(l Payment Type ✓ Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003