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Apr 02 12 11:51a Reliable Petroleu 209-845-8953 p.3 N JOA _ AIDUNTY ENVIRONMENTAL HEALT PARTMENT SERVICE RFOITFN I; Type of Business or Property CONTRACTOR / SERVICE REQUESTOR FACILITY iD# Al -Pf-. CHECK If BILLING ADDREWIM SERVICE REQUEST # PHONE# ExT. f- `11�'L4,W1 .l�t�V� LAS —}—Y� rr • Gy �ZS � c"3 3Z G ( i-�v r s-� s !-t � �.- � FAX# i Z 3 5-S (�- f 1 3 'S OWNER I OPERATOR BILLING A KNO�VL GEMENT: I, the+undersigned property or business owner, operator or authorized agent of same, acknowledge that ail site E ndior project specific ENVIRONMENTAL HEALTF1 DEPARTMENT hourly charges associated with this project v I � �,��! I also certify that I have p pared this application and that the work to be performed will be done in accordance with all SAH JOAQL,,IN COLFNTY^ Ordinance Codes Standards, STATE and FEDERAL laws. j}�� CHECK if i31LUDIG ADDRESSO FAcIL17Y NAME G %' + 5 0 —DEP -DE P1 - I -r- OPERATOR/ MANAGER Q OTHER AUTI3017ZEDAGENT 14 C %`✓ G^�. ` r, rffiPPLfC.4. SITE ADDRESS '•J3 C) Street Nu E Ger t' -J 0 Se -I Vi l fi e. , ,J J/1.0.0t C. 9533 }TOME or MAILING ADDRESS direction Street Name If Different from Site Address} QUIN COUNTY ENv1RONMENTAL HEALTH DEPARTMENT as•soon as it is available and at the same time it is G ZI Code CITY Street Number SVeet Name DATE: 41 Z l 2— Date Service Completed (if already completed): STATE zip PHONE #1 EX*- 3 -2- APN # LAND USE APPLICATION # PHONE#2 ( } EXT. yL� BOS DISTRICT --]Fi.00ATION CODE TYPE OF SERVICE REQUESTED: CONTRACTOR / SERVICE REQUESTOR REQUESTOR (-7:. L4-CL(.4 Al -Pf-. CHECK If BILLING ADDREWIM BUSINESS NAME rC,il PHONE# ExT. f- `11�'L4,W1 .l�t�V� LAS —}—Y� rr • Gy �ZS � c"3 3Z HOME or MAILING ADDRES ( i-�v r s-� s !-t � �.- � FAX# IRECEIV r_9 (�- f 1 3 CITY �`icl r -A& STATE CA— ZIPl�r� 7 J BILLING A KNO�VL GEMENT: I, the+undersigned property or business owner, operator or authorized agent of same, acknowledge that ail site E ndior project specific ENVIRONMENTAL HEALTF1 DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have p pared this application and that the work to be performed will be done in accordance with all SAH JOAQL,,IN COLFNTY^ Ordinance Codes Standards, STATE and FEDERAL laws. + A[ [ LI ANT"S SIGNtil RE: .......'•ar:+=c»st :..+.c « �,,...pr, "'•.�� i DATE: (: Ll- v Z- -1 L PROPERTY/ BusENESS OW\'E I -r- OPERATOR/ MANAGER Q OTHER AUTI3017ZEDAGENT 14 C %`✓ G^�. ` r, rffiPPLfC.4. -f is not the BTI.Lf.'vG PaRT, proof of authorization to sign is required Tide AUTHORIZATION TO ELEASE 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 environmentallsite assessment information to the SAN JOA QUIN COUNTY ENv1RONMENTAL HEALTH DEPARTMENT as•soon as it is available and at the same time it is provided to me or my repTe entative. TYPE OF SERVICE REQUESTED: 6-t' COMMENTS: IRECEIV r_9 IAPR tZIM .,, JoAQURN r -C)"" EM/1RONMENIW�� DEPS H�1}{ ACCEPTED, BY: �D v'� EMPLOYEE #: DATE: ✓� ASSIGNED TO: li" q b I dV 1 a EMPLOYEE #: �`, DATE: 41 Z l 2— Date Service Completed (if already completed): DE: P 1 E: jj yL� Fee Amount: '? S Amount Paid d(� %S a Payment Date 1 2 -- Payment TypeV I c Invoice N - Check # V — Received By: EHD 48-02-025 REVISED 11117/2003 L SR FORM {Golden Rod}+