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Aug 13 12 12:25p Reliable PetroleumA 209-845-8953 p.3 <br /> N N <br /> SAN JOAQUIN COUNTY.ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Pr operty FACILITY ID# <br /> ^� <br /> 'CIL+ n SERVICE REQUEST <br /> OWNER OPERATOR W �� ` o`f <br /> n ��' ✓I � CNECf(if BILLING_ A� DpRESS Q <br /> FACILITY�lAt1E <br /> SITE ADDRESS � . <br /> Street umber D re on 5v-1... 00 �iO (+i„���CiL� <br /> HOME or MAILING ADDRE (if Different from Site Address) t � ��de <br /> zI come <br /> CITY SireetMumber Ste awe <br /> STATE zip <br /> PHONE#1ErT. APA/# <br /> [ q} $ � (q U-2- �; LAND Use APPLICATION# <br /> PHONE#2 EXT. <br /> ( ) SOS USTRICT � LOCATION CODE <br /> C <br /> REQUESTOR <br /> CONTRACTOR I SERVICE REQUESTOR <br /> ff��`` <br /> BUSINESS NAME CMECK if$1LLING_ADDRESS <br /> I�t PHONEf <br /> � <br /> HOME or MAtuNG ADDRE S FAX# o <br /> t 11l3r� Nvs1 2d. , q) <br /> STATE (Z,4- ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same. <br /> acknowledge that all site and/or project Specific ENVtRQNil4ENTAL HGALTN I3EpARTM$VT hourly charges associated with this project <br /> or activity will be billed t me or my business as identified on this form. <br /> I also certify that I have r repared this application and that the work to be performed will be done in accordance with all SAN JOAQUN <br /> COUNTY Ordinance Cod ,Standardv. STATR and FFnr.RAr.Lgws. <br /> APPLICANT'S SIGN. URE: <br /> DATE: <br /> PROPERTY/BUSIrVE%$()W 1' •IJ3 <br /> ERA'rOt2JMANAGER1­71 QTrIERAL'THORILEDAGENT�J�n�Y�'r,�-�ZT� <br /> If APPLiC,t 'T is not the 31L1.LVG'PAP7'Y,proof of,7zttkorizativA to si�►t Is required Tflle <br /> AUTHORIZATION T RILE SE EllFQAh ATIQN; When applicable,t,the owner or operator of the property located at the <br /> above site address, her y authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to The SAN JO kQLIN COUNTY F-NVIRONMrNTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is <br /> provided to me or my repr sentative. <br /> [AcCEF7ED <br /> =E1 <br /> PLL 1�+ t I�`,7 Y ��T <br /> �t SEC tV�® <br /> p,UG 4 2012 <br /> i SAN�.0 'J"CC)UHn <br /> EIM ONWE TMENT <br /> HF�L <br /> DE <br /> EMPLOYEE#: ��L�T} 3 DATE' <br /> ASSIGNED TO: N EMPLOYEE#: ' <br /> DATE; ( - <br /> Date Service Completed 'f already completed): <br /> SERVICE CODE: l P!E: <br /> Fee Amount: Amount Paid <br /> V 3-75-. 0-0 Payment Date I I f I <br /> Payment Type (5 Invoice# Check# <br /> Received By: <br /> EHD 48-02-025 <br /> REVISED 1111712003 SR FORM(Golden Rod) <br />