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Feb 15 11 05:06p <br />Type of Business or <br />Reliable PetroleU44 0 2#5-8953 p.3 <br />AN JOAQUIN COUNTY ENVIItONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />'rO FACILITY 1D # I SERVICE REQUEST # <br />� -t�� 0-L) ' Z 1. SRO f <br />DINNER I OPERATOR <br />inti -e t_ <br />,e <br />I< ,_/Ile h rOK -e,. <br />FACILnY NAME # t S U-) & C- . <br />SrTEADDRESSt t 1, <br />Street r4mbar Direction tolen Sheet N <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />CITY <br />9) 9 Ll -,-ON - <br />PNDRE#2 <br />REQuESTQR Rob <br />BUSINESS NAME <br />HOME or MA Lwe ADDRE: <br />acknowledge that all site <br />or activity will be billed t <br />I also certify that I have F <br />COUNTY Ordinance Code <br />APPLICANT'S Slf <br />PROPERTY 1$USLNESS <br />-ff,4P. <br />above site address, herel <br />information to the SAN JO, <br />provided to me or my rept <br />TYPE of SERVICE ReQUESTED: <br />c <br />E.11- <br />3� L1 <br />EXT. <br />,UJ1%6` <br />CtfFcx if AJUM ADDRESS ❑ <br />STATE ZIP <br />LAPID USE APPLICATION # <br />BOS DIST=r LOCAnON CODE <br />CONTRACTOR f SERVICE REQUESTOR <br />?� I y�Y CHECK if BILLING &DORESS <br />LLJ�e /Qe Iry 1 f~ u M Se. r V i, tr e-, j aYl C. 49 <br />NE # Exr. <br />51193b tivrs�shv e. l2ua0/ (-Q0,T 9S-3 <br />STATE <br />;DGDGEWNT: I, the undersigned property or business owner, operator or authorized agent of same. <br />Indlor project specific EP7vTRONMENTAL H tLTH DEPARTMENT hourly charges associated with this project <br />me or my business as identified on this form. <br />-epared this application and that the work to be performed will be done in accordance with all SAN ioAQUIN <br />Standards, STATE and FEDERAL laws. <br />URE: i rata t ri.hc i %C`l >. DATE-- <br />OPERATOR/ <br />ATE:OPERATORI NWrAGBR 0 OTHER AtM40R r MAcznrr M (' I) <br />T is not the BIt,LIMG P rYRproofp,f'aoa0=4 i00 to s4p ijreqnjred Title <br />RELEASE iNFOR1VCA7ION: When applicable, L the owner or operator of the property located at the <br />y authorize the release of any and all results, geotechnical data and/or environmental site assessment <br />,QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT assoon as it is available and at the same time it is <br />senrativE_ <br />Dints Rio: o f \ AC-IkA <br />ACCEPTED BY: —r -)L <br />ASSIGNED To: <br />Date Service Comp) <br />Fee Amount: 409 <br />Payment Type \� \ <br />EHO 4"2-025 <br />REVISED 1 111712003 <br />44. 4 <br />P u RECEIVED <br />FEB 16 2011 <br />SAN .jnAOUIN COUN <br />alreaft completed): <br />Amount Paid <br />invoice # <br />PE,MPL0,YEF,P,,,ni1 Date <br />Ca V% O�S28 Cs <br />HEALTH UtVAM 1 mCIV I <br />DAIS <br />DATE: <br />PI E�f r� <br />ROCeked By:'M <br />SR FORM (Golden Rod) <br />