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Jun 24 10 G�9:53a Reliable Petroleu 209-845-8953 p.3 <br />SAN JOAQU IN COUNTY ENVIRON MENTAL HEALTH DEPARTMENT <br />SERVICF. RFf1ur.vT <br />Type of Business or Property FACILITY ID # <br />�TJ� r� ass <br />OWNER IOPERATOR <br />SERVICE REQUEST # <br />5�0060 <br />CHECK if AIL Ca_ADDRESS0 <br />FACILITY NAME A <br />SITE ADDRESS <br />Street Number I <br />� C �S-33 (47 <br />Direction Street Name <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />-"q— <br />Cd zl Cotle <br />Strom Number <br />CITY <br />Street Name <br />STATE zip <br />PHONE A "• APN # <br />('�Oq) �Z.S--��33Z� 2,2-1- 2ov- .53 <br />LAND USE APPLICATION # <br />PHONE #2 Exr. <br />BOS DISTRICT �- LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />RE4UESTOR L�2 <br />� � -f- f� rt)'r'� t t ✓� Y CHECKif BILLING ADDRESS �LI <br />BUSINESS NAME <br />is J �r�I5 PHi-�.s-E.st Ex7. <br />HOME or MAILING ADDRESS r <br />FAX # <br />►�G��� I r Y !�0 q) yyS- <br />CITY I ',r, 1� (1 STATE C A- Zip <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVLRONMENTAL 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 JOAQUIN <br />COUNTY Ordinance Codes, Standards, S'L'ATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: r �Yl�i��u� rt kG+i G =� <br />DATE: lk, <br />PROPERTY/ BUSINESSOWNFRE7 OPERATOR NfANAGER ❑ OTIIERAUTfioRfzEoAGEN"I' � �l�j Ch <br />APPLICA.vT is not the BILLiATG PARTY, proof of aut11oriyntlOn to sign 1s required Thle <br />A <br />AUTI{ORtZTION TO RELEASE INFORMATION: 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 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED:"�� <br />COMMENTS-. <br />�tS D <br />kuy- �\ \CZ , <br />ACCEPTED BY: <br />ASSIGNED TO: A4 t O L,(- <br />Date Service Completed (if already Completed): <br />Fee Amount: 3 s Amount Paid <br />Payment Type S Invoice # <br />`��S <br />EMPLOYEE <br />EMPLOYEE #: 2670 <br />SERNCE CODE: , <br />3 4 S _ Payment Date <br />Check # <br />EMD <br />REVISED 1111712003 ;)� OVA-(-- <br />V'( U <br />C35 <br />Q � 6- <br />JUN 2 4 2010 <br />IN COUNTY <br />DATE: O <br />147 <br />�O 2gfca <br />Received By. nRy <br />SR FORM (Golden Rod) <br />K.� <br />