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Jun 24 10 02:50p Reliable PetroleumA 209-845-8953 p.3 SAN JOAA COUNTY ENVIRONMENTAL H EALTH DEPARTMENT Type of Business or Property SERVICE REQUEST FACILITY ID # SERV 1� OWNERf OPERATOR .� �i��T� A-1 l K e-� L{ r � FACILITY NAME CHECK if BILLING ADDRESS C11'v�n12.r M d1L C'v'�D{� SITE ADDRESS '2��Li } a �A /� �/ J Street Number Diracfton - �M tr LA-' q Gi 71 (}� Z �f HOME or MAILING ADDRESS (If Different from Site Address) street Nam ' v 7 e �/ cityzf code CITY Street Number tree! Name STATE ZIF PHONE #1 G �p EXT. ('909) � % D � t Z � � APN # A LAND USE APPLICATION # PHONE #2 EXT. 0 ) 8CS DfSTRICT LOCATION CODE REQUESTOR � 0 10 cr+- CONTRACTOR/ SERVICE REOUEST41P ba>; ' n k C'-C-}-- BusiNESS NAME I v HOPAE or MAILING ADDRESS �Z_ I Brar�cll;v�c CITY 04k ✓ &R—p -P CHECK it 1LLING ADDRESS PHOS FAX 3t�y) 4';S'3 STATE �^ A ZIP 9s3 / SICCING ACKNOWLEDGEMENT: I, the undersigned property business owner, operator or authorized agent of same, acknowledge that all site and:'or project specific ENviRQNMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be hilted to me or my business as identified on this form. 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 COUNTY Ordinance 'odes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: PROPERTY/ BUSINESS()1,WFR❑DATE: OPL+RATOR/ NTANAr-F,R ❑ OTtIERAtrr110rtIZ$DAGrN'1' RJAAi ) (" IfPPLICA.N�T is not the B//_LLVG PAR77 proofO .autlroriyatton to sign is required Title J AUTHORIZATION TO RELEASE 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 environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTE DEPAR'm1EN-r as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: ACCEPTED BY: ASSIGNED TO: � Date Service Corr Fee Amount: C Payment Type EHD 48-02-025 REVISED 11117/2003 rl PAYM NT V0 I/ RECE _ ED JUN 2 2010 SAN JOAQ COUNTY ENYIRO MEWTAL HEALTH D ARTMENT EMPLOYEE #: EIapLOYEE # i / 36 (if already completed): SERVICE CODE: �%� Amount Paid 3�S D (� Payment Date invoice # p Check # q 6 r ! E: 9'1z) Received BY; SR FORM (Golden Rod)