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Aug 12 09 11:20a Reliable PetroleumA 209-845-8953 p.3 <br /> SAN JOAQUIPCOUNTY ENVIRONMENTAL HEALT EPARTME)1T <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST# <br /> G-bF 13& �cc ss' (D-IL— <br /> OWNER I OPERATOR <br /> ' Jay 4 �� ` I wayl� CHECK If BIILq�G ADDRESS <br /> pFACILITY NAME �} (((���l�l• ` I <br /> SITE ADDRESS 2- / 5 <br /> Street Number DlrecUan Street Name city Zip Cc <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number MMet Name <br /> CITY STATE zip <br /> PHONE91 ExT. APN LAND USE APPLICATION# <br /> (909 ) `� ,� -�skv 0-"- ?mac -0 L- <br /> PHoNE#2 Ems• BOS DISTRICT — LOCA710NCODE <br /> CONTRACTOR! SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEf� PHONE# n Exr'i r-es �k1C - S-- �'s ' <br /> HOME or MAILING ADDRESSr g1,�11 t i� FAx# <br /> J ci v r, (Xfi , " -3 <br /> CITY 0(xV'(k0"\ STATE 0 ZIP Vs–L3 6/ <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENrrAL 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 l have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQU IN <br /> CouN'TY Ordinance Codes,Siandards STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: U I DATE: 9/11 o <br /> PROPERTYIBUSINFSSOWNEItCJ OPERATOR/MANAGER 0 (krFiERAVI'HORIZEDAGENT Vf6rN=: fifl.l-jTl <br /> If APPLICA,tiT is not the BILLI,°VC PARTY.proof of autkoriZation to Sign is required riite <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,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 SAI;JOAQUrN1 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. LCST <br /> TYPE OF SERVICE REQUESTED: 91 M LLDU) For G10 91 C goo <br /> COMMENTS YMENT <br /> a�AG E{V <br /> EE <br /> AUGG 12 200 <br /> 'SAN JOAQUIN COU slTY <br /> ENVIRONMENTA <br /> NT <br /> ACCEPTED BY: A 9 t 1 EMPLOYEE f: v &z4 DATE: Y1 1 2-4 <br /> ASSIG �if^ <br /> NED TO: 6A r j � EMPLOYEEft L�j3 DATE: t� 1409 <br /> Date Service Completed (if al�ready completed): SERVICE CODE /�j�' P 1 E: z-309' <br /> Fee Amount: 3`F.� Amount Paid 3 5- t)-0 �31D Payment Date C <br /> Payment Type AA4 W Invoice Check# Received By: _ <br /> EH 48-02-025 it S` S� SR FORM(Golden Rod) <br /> REVISED 11IM712003 <br />