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' 4 <br /> SAN JOAQLWOUNTY ENVIRONMENTAL HEALTIDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Snf 11 Oil CompOnY- T-Pyrnino SIZ4d '7o8os <br /> OWNER/OPERATOR <br /> S I I 1 ,/ I I CHECK If BILLING ADDRESS <br /> FACILITY NAME S I I I I Il cofflDdn� <br /> ) r <br /> SITE ADDRESS 351 J A I/lv\( 111.1/p stoaton q,52c)3 <br /> Street Number Direction �V lA 7 L YStreet Name r` city I Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number I Street Name <br /> CITY STATE ZIP <br /> PHONE#1 En. APN# LAND USE APPLICATION III <br /> (gIL413-7 - I1 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR -t— <br /> I G }1 i r <br /> m r ori cpE I Inc . <br /> CHECK If BILLING ADDRESS� <br /> BUSINESS NAMEPHONE# EXT. <br /> &212 <br /> HOME or MAILING ADDRESS FAx# <br /> nt Drl 0 1A ) <br /> CITY 1 v STATE /1 ZIP 9 -2L W <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 <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 SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: tA710MIDATE: 1 0 1 1412(I l 4 <br /> PROPERTY(BUSINESS OWNER❑ OPERA? R/M NAGER 13 OTHER AUTHORIZED AGENT g / to/ f <br /> I,fAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the same time It Is <br /> provided to me or my representative. n� p� <br /> TYPE OF SERVICE REQUESTED: �ST MENT <br /> COMMENTS: D <br /> OCT 16 2014 <br /> SA ENV ROMENTAL� <br /> FIEALTN DEPARTMENT <br /> ACCEPTED BY: i _ / L EMPLOYEE#: DATE: tQ//(, <br /> ASSIGNED TO: el v EMPLOYEE#: 1 �/ DATE: 10 1(p 1 <br /> Date Service Completed (if already completed): SERVICE CODE: /-y 8 PI E:�3D7n' <br /> Fee Amount: �i L Q Amount Paid 2p0 Payment Date <br /> Payment TypE Invoice# Check# �j�j�o Received By: L6 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />