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Jun 23 14 04:29a Reliable Petrol- -,n 20P8458953 p.3 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> IN 2 3 2014 SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ENV NMENTAL- IEALTH(-,,2D F <br /> Y-) LC <br /> -e— CNFCKif BIL NG ADDREss❑ <br /> FACILITY NArdE i \t ` � G d U 6 I r,, <br /> SITE ADDRESS ��L1 �1 a l r1 St r e e Sfia �}c j j-� 9sal>> <br /> Street Namber Diroctim Street Name City Zip Code <br /> HomE or NAILING ADDRESS (If Different from Site Address) <br /> Strom Numner freer Name <br /> CITY SPATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICA-ION# <br /> PHONE#2 EXT. BOS DISTRICT LOCA-ION CGDE <br /> ( I <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> O'b e r4- (vY Y\�i1L Y- C <br /> HECK if BILLING ADDRESS <br /> BUSINESS NAMI�C.. <br /> E ''tK't..✓1,y+...JJ1� p+fe i t�L,11-1 •��T V 1 L f' !�('. PC <br /> HOME or MAILING ADDRESS 1030 ]i JD�.seshd e <br /> CITY c.y / STATE CA J ZIP �lJ 3& <br /> BILLING ACKNONVLEDGENIENT: 1, the undersigned property or business owner, oper+attor or authorized agent of same. <br /> acknowledge that all site and/or project specific ENVIRONMENTAL 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 I have prepared this application and that the work to be performed will be done in accordance with all SAI;JOAQUiN <br /> COUNTY Ordinance Codes,Standards. STATE and FEDERAL laws I <br /> APPLICANT'S SIGNATURE: U-);ZV04DATE: Co- <br /> { rP 3 .-{��7, <br /> PROPERTY!BUSINESS OWN FR[3 1'ERATOR,.NIANAGER ❑ OTHER. LITHORIZFDAGEM Igr` `-ntracl (Jr— <br /> If APPLICA,N`T is not the BILL1N6'?.4P.T'r'proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,the owner or operator of the property located at the <br /> aoove site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaL/site assessment <br /> information to the SAN JOAQUIN COUNTS' ENVIRONMENTAL HEALTH DEPARTMENT 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: /CV<T ��� /c { '�T7� C <br /> COMMENTS: r ac- <br /> ACCEPTED BY: /Y l �19''t 2 l/\ EMPLOYEE#: 76 70 <br /> ASSIGNED TO: �IN EMPLOYEE#: ely 9 9 DA-E: <br /> Date Service Completed (if already completed): SERVICE CODE: 1q PIE: <br /> Fee Amount: '�TAmount Paid< VS-,©o Payment Date �Z T <br /> Payment Type I rs�y Invoice J Checktl ' Ocl 7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REV;SED'1 t 17r�003 d <br /> 1�q �,�.i�l <br />