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Dec 05 11 05:30p Reliable PetroleumA 209-845-8953 p.3 <br />S <br />JOAQUE*UNTY ENVIRONMENTAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Type of Business or Prop <br />FACILITY ID # SERVICE REQUEST # <br />��� -F <br />j 2 ass S"R� � 4�.3�� ' <br />OWNER/ OPERATOR <br />u p f' <br />I r' klr CHECK If BILLING ADDRESS <br />FACILITY NAME GaS <br />d f 2 <br />SITE ADDRESS + `3 3 <br />J <br />Street Nu <br />v05e % tC <br />lertDirection <br />HOME or NAILING ADDRESS ( <br />Street Name Cd Zip Code <br />Different from Site Address) <br />CITY <br />Street Number Slreet Name <br />STATE Zip <br />PH0NE#1 <br />EXT, APN # LAND USE APPLICATION # <br />32 <br />PHONE #2 <br />( ) <br />EXT• I30SDISTRICT LOCATION CODE <br />CONTRACTOR 1 SERVICE REQL:ESTOR <br />REQUESTOR <br />CHECKifBfLLINGADDRE S1 <br />BUSINESS NAME <br />MotaE or MAILING ADORES <br />FAX# <br />, �30 �}orses�ro a (94 8` ys�- e9'5,3 <br />CITY <br />Q L a -I <br />STATE ZIP 57 <br />BILLING ACKNOWLE <br />acknowledge that all site a <br />GEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />d/or project specific ENVIRONMENTAL <br />HEALTH DEPARTvIEN'r hourly= charges associated with this project <br />or activity .-ill be billed to ie or my business as identified on this form. <br />1 also certify that t have pr <br />COL;NTY Ordinance Codes, <br />ared this application and that the work to be performed will be done in accordance with all SAN JOAQL:IN <br />Iandards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNAT <br />RE: <br />DATE: I2-0S-Jj <br />PROPrRTt / BUSINESS OWNER <br />OPERATOR t INANAGER ❑ OTI IER AUTHORIZED AGENT <br />is not the BILLING P,4RTY. proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE <br />above site address, hereb <br />INFORMATION: When applicable, 1, the owner or operator of the property located at the <br />authorize the release of any and <br />information to the SAN JOA <br />all results, geotechnical data and;or environmental site assessment <br />UIN COUNTY ENVIRONMENTAL HEAi.,TH DEPARTR4ENr soon as it is available and at the same time it is <br />provided to me or my repre <br />ntative. L( _ A $d , A) 6— 0/4, 2 <br />TYPE OF SERVICE REQUESTED:u <br />A[L t` 0. <br />W <br />4"'�4PAYME <br />COMMENTS: /� <br />mss' <br />�� ) 'wi- <br />' IN) 90). <br />�L <br />RECEN <br />DEC - 6 <br />ACCEPTED BY:tiLi t1c.[ 4A EMPLOYEE #: b % DATE: <br />Ai%siGNED TO: <br />'�� r l t( <br />rI l� EMPLOYEE �� U DATE: <br />Date Service Completed (ifalready completed): SERVICE CODE: C� PIE: <br />Fee Amount: I ?S c`ti Amount Paid Payment Date3—]5-7 I I I <br />y <br />Payment Type V 5# heck Invoice # C <br />Received Bv;,-I-Af, <br />EHD 125 <br />REVISEDSED 1111712003 <br />71 11 7/2 0 03 I ^ l+ o . /✓1 * Or70 SR FORM (Gorden Rod) <br />�T C__ <br />