Laserfiche WebLink
Dec 07 10 01:48p Reliable Petrol A 245-8953 p.8 <br />r <br />AN JOAQUI N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Pro <br />rty <br />GDF <br />FACILITY ID # <br />CA 20 2 ' <br />SERVICE REQUEST # <br />s4o4,/(0 /� <br />OWNER I OPERATOR <br />p j1 <br />l.Li' I ✓1 iJ LL <br />CHECx if Bi W NG ADDRESS ❑ <br />FAciLm NAME /1 <br />—DC-POT- <br />DC-P/T-SITE <br />SS � � � Q � � � i1 <br />SITEADDRESS <br />� <br />Street Number <br />9-- 9 S= !�' � S 3 <br />I' rt-e—A v' In <br />sft"Mame <br />C' <br />`r' <br />Zi Cale <br />(TOME or IUI111L1A{G ADORES <br />(If Different from Site Address) <br />Street Nemberl <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE#t <br />IdOq) �B2L7j- <br />E.T. 71APN <br />32 <br /># <br />LAND UsEAQPuCATmON# <br />PHONE 92 <br />( ) <br />E -F. <br />SOS DISTRICT <br />LocA=N CODE <br />CONTRACTOR ! SERVICE REOUESTOR <br />REQUESTOR I <br />� <br />CHECK ifSiLuNGAooREssQ <br />BUSINESS NAMEI <br />6'i ►'t <br />�.fe L-itC P . <br />PHor E# <br />En <br />HoME or !{lIA1tJNG ADD <br />SS � � � Q � � � i1 <br />EMPLOYEE #: lq <br />txl) <br />9-- 9 S= !�' � S 3 <br />CITY oqt <br />STATE � <br />ZIP 9s 3 Ce <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all sit a andfor project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQurN <br />COUNTY Ordinance Coe. es, Standards, STATE and FEDERAL I ws. <br />APPLICANT'S SIGNj LTURZ.- C DnTE: oma' 1 <br />PROPERTY I BUSINESS OW -1ER❑ PERATORfMANAGER ❑ 0TKERAUTa0RtZCDAGENT Q dlam' <br />If APPL1 is not the BILLIKG PAR7T. proof ofauMorkadon to sign is required Title <br />AUTHORMATION T RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, he vby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN i OAQUIN COUNTY ENvIRONMENTAL HEALTi-I DEPARTMENT as soon as It is available and at the same time. it is <br />provided to me or my re nesentative. <br />TYPE OF SERVICE REQu <br />U" tib rL VA4 Z <br />19, <br />cogs: <br />6'i ►'t <br />�.fe L-itC P . <br />.:. _ . <br />RECENED <br />DEC 0 3 2010 <br />SAN JOAQUIN COUNTY <br />TAL <br />ACCEPTED BY: <br />EMPLOYEE #: lq <br />liA fA4� �U P ENT <br />/b, L <br />ASSIGNED TO: <br />EMPLOYEE M "% <br />` <br />DATE: <br />Bate Service Complete <br />(ii alrea y completed). <br />SERVICE CODE: <br />PIE: 2 8 <br />Fee Amount: <br />Amount Pairs <br />Payment Date <br />Payment Type V <br />Invoice # <br />Oheek 1.Received <br />By: <br />END 48-02-025 SR FORM (Golden Rod) <br />REVASED 11117/2003 <br />