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Feb 17 1.2 08:21a Reliable PetroleunnA 209-845-8953 p.19 <br />AN JOAQ1000UNTY ENVIRONMENTAL 11EAL0. DEPARTMENT <br />SERVICE REQUEST <br />Type of Business Or Pro rty FACILITY !D # <br />SERVIC REQUEST # <br />OWNER /OPERATOR }� e <br />JAe n ` ro rl-e— CHECK if BILLING ADDRESS <br />FACILITY DAME � � � � l� <br />SITE ADDRESS Lk) L S O V't 06k`/f) <br />Street N u ger Direction Street Nam® <br />HOME Or MAILING ADDRESS i if Different from Site Address) <br />C. <br />n coae <br />CITY Street Number Street ame <br />STATE Zip <br />PHONE #1 EXT. APN # <br />( !1e\GI) C 12 2 U LAND USE APPLICATION # <br />PHONE#2 t 1 ExT. <br />( } BOS DISTRICT LOCATION CODE <br />REQt1 ESTOR <br />CONTRACTOR / SERVICE REOVESTOR <br />{ n <br />G `LJL0 t�l UL t CHECK if BILLING ADDRESS E4 <br />BUSINESS NAMEPHONE# Ex-,. Ser Lai L-e s -t,,C C. <br />HOME Or MAILING ADDRESS <br />FAX I ("� # Q <br />CITY /^. ( 1 `�(3i1 rse$1-lv t (dem) gIls G CtS <br />t/CLILAai STATEC A ZJP <br />BILLING ACKNOWLE GEiytENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site a id/or project specific ENVIRON IENTAL HF.AL'''IJ DEPARTMENT hourly charges associated with this project <br />or activity will be billed to ne or my business as identified on this form. <br />1 also certify that i have prepared this application and that the work to be perfonned will be done in accordance with all SAN JOAQ(1-IN <br />COUNTY Ordinance Codas, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: z 11 f �� _ <br />DATE: <br />PROPERTY/ BUSINESS OWNG ❑ OPERATOR t MANAGER ❑ OTHF,R AUTHORIZED AGENT � �� `�A 0:�7} <br />flAPPLICA is not the BILLING PAMTY: proof of aurliori atiotr 10 sign is required Title <br />AUTHORIZATION TO EL-EASE IN ORMATION: When applicable, 1, 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 JOS UIN COUNTY ENVIRON-MENTAL HEALTI•i DEPARTMENT as soon as it is available and at the same time itis <br />provided to me or my repre ntative. <br />TYPE OF SERVICE REQUESTED: t ek � � (> C � c��� o �� FOK J� <br />COMMENTS: Y' �? v <br />ACCEPTED BY: EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: EMPLOYEEDATE; <br />#: -� <br />Date Service Completed (if already completed): SERVICE CODE: <br />P f E: <br />Fee Amount: Amount Paid Payment Date <br />Payment Tyne Invoice 4 Check # <br />Received By; <br />EHD 48-02-025 <br />REVISED 11;1712003 ( R FORM 'Golden Rod) <br />1 <br />