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Jul 25 13 05:26a Reliable Petrol- -i 2r '458953 RECEIVED <br /> JUL 2 5 2013 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> ENVIRONMENTAL SERVICE REQUEST HEALTH DEPARTMENT <br /> Type of Business or Property FACILITY ID# JERVICE RE EST# <br /> 6'D('7- A- I L <br /> OWNER i OPERATOR <br /> -y'- /V CHUCK If BILUNG ADDRESS❑ <br /> FAcLrrYNAME <br /> SITE ADDRESS �{ �!0 �� 'SID U LA 6 9 S Z ©.S'` <br /> Street Nunbar re lion v S Z C <br /> Hoff Or MAILING ADDRESS (if Different from Site Address) <br /> Street Streat Name <br /> CITY STATE Z P <br /> NONE#1 E-T- APN* LAND USEAPPUCATION# <br /> gaol <br /> Li L, <br /> PHONE#2 Ext. SOS DhSTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> ob-co-- � ���'n��� CHECK If 61LUNG ADDRESS <br /> BusmEss NAME , * HONE# Ex,,,4z 1 te>`ti�� �f:tri+1 ►�, <br /> So( , c,.e/z _ o g1ts 6, f� 2 <br /> HOME or MAI u NG ADDRESSh q:�>o S l d`� -f' 009 1 �•`I S— O q '5 ./ <br /> CITY �c. j���' Y1 �GJ1 TATE CA ZIPy5-- <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned propyorbusineowner, operator or authorized agent of sante, <br /> acknowledge that all site and/or project specific ENVIRONMENTATMENT hourly charges associated with this project <br /> or activitywill be billed to me or my business as identified on thiI also certify that I have prepared this application and that the wowill be done in accordance with all SAN JOAQUIN <br /> COI;NTY Ordinance Codes,Standards;STATE and FEDERAL laws. <br /> APPWCANT'S SIGNATURE: Lo" DATE; /1 0' <br /> PROPERTYIBCSINESSOWNER❑ OPERATORIMANAG/F-4,LTH <br /> OTHER AUTHORImmAGEN'T9 <br /> IfAPPLICANT Is not the BILLING PARTY proization to sign is required rwe <br /> AUTHORIZATION TO RELEASE INFORMATIONlicable,1, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of anesults, geotechnical data and..or environmentaVsi'a assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTDEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED:: <br /> y <br /> ACCEPTED BY: EmPLDYEE#: DATE: <br /> ASSIGNED To: E',MPLDYEE JI: DATE: <br /> Date Service Completed (if already nVleted): SERWE CODE: P I E <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD SED 1111 / SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> J� <br />