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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 0 ;SERVICE REQUEST is CONTRACTOR 1 SERVICE REQUES IUK REQU ESTOR Central Petroleum & Maintenance CHECK if BILLING ADDRESS ❑ PHONE # Exr. BUSINESS NAME Central Petroleum & Maintenance 925 462-4060 HOME or MAILING ADDRESSFAx # 176 Wyoming Street ( 1 CITY Pleasanton STATE CA ZIP 94566 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL 14EALTH DEPARTMENT hourly charges associated with this project or activity will be billed 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 Codes, Standards, STATE and FEDERAL laws r'"` �A September 14, 2008 APPLICANT'S SIGNATURE: �I DATE: PROPERTY / BUSINESS OwNERO OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT ❑ IfAPPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title 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 infonnation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Cold Start prior to the required inspections on 2 separate occasion 1213108 and 1121!09 for work on u a COMMENTS: ' SEP 1 5 2009 EN PIERMIT/SE.RKES HEALTHENT ACCEPTED BY: ASSIGNED TO: Date Service Completed (if already completed): Fee Amount: r,,Q/'j 4r6 Amount Paid Payment Type EHD 48-02-025 REVISED 11/17/2003 j� 1invoice # EMPLOYEE #:KCODE' DATE: EMPLOYEE #: DATE:SERVICP I E: Payment Date r Q Check # ' v1 o l -k 6 5 Received By: SR FORM (Golden Rod)