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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FAY ID N SERVICE REQUEST# <br /> CIO <br /> frrdc-�✓ �"t ��+ 4 V FACILITY <br /> OWNER l 6PERATORA�. / CHECK if BILLING Wo REst <br /> FAULayNWNEf< <br /> A. J <br /> JSI ESSY,/TF ADDR 'X X.,1A �tih YO 0-13✓-) <br /> f� ` Slreef Number Dircelian Sira t ame CI[ Zi Cade <br /> HOME-Of MAILING ADDRESS (If Different from Site Address) <br /> Street Number SIreet NaIEC E 11 <br /> CITY STATE <br /> V 174 <br /> PHONE pl <br /> Err. APN#1: lallo USE APPLICATION# �� � �� <br /> Vey X ��3'- <br /> PuoNEA2 E>* eQSDIsrRICT LNVL[tO 111ENTALHC STH <br /> f ) PA It I NILI <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR Greg Kaiser CHECK if BILLING A1)DRESS0 <br /> PIIDNE# EAT.f3USINEssNAME Kaiser Commercial Petroleum 202 887-2639 <br /> WOMB Or MAILING ADDRESSFAx k <br /> 17p Box 105$ <br /> t ) <br /> CITY Linden STATE CA zIP 95236 <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 ENVIRONMENTAL. HEALTH DEPARTMENT hourly charges associated with this project or <br /> 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 to performed will be done in accordance with all SAN JOAGIUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws <br /> APPLICANT'S SIGNATUREA- DATE: <br /> f /' <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANAGER ❑ <br /> OTHER AUTHORIZED AGENT &:/'tS <br /> wtr<ta�� <br /> If APPLICANT is 001 Ille BftL(NG DARTY proof of authorixafion to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: Wizen applicobla, I, the owner or ererator of the properly located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data andfor environmentallsite assessment information <br /> to the SAN JOAQUIN CouNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is provided to m or <br /> my representative. "n <br /> u � �4,q <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS:-- <br /> 1/7 Q�Jlv <br /> r <br /> y�4T aF C. <br /> N7�, <br /> T <br /> ACCEPTED BY: EMPLOYEE#: d�I DATE: <br /> ASSIGNEDTO: 1E EMPLOYEE: DATE: -0 <br /> Date Service Completed (if already completed): SER E CODE: (q PIE: '�' , 09 <br /> Fee Amount: Amount Paid " .06 Payment Date <br /> Payment Type Invoice# Check# S ReC ved By: <br /> F-iiV <br /> `n N F�t hi4�Golden Rod) <br /> E1•ID 4(1-D2-D25 .] <br /> 67f 17lD8 <br />