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Mar 31 09 02:07p Reliable PetroleumA 209-845-8953 p.3 <br /> SAN JOAQUID, . OUNTY Fo"VIR104-MENTAL HEALTH 0EPARTMENF <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 01 <br /> OWNER l OPERATOR <br /> J` rS <br /> S � �� CHECK If BILLING ADDRESS L <br /> FACILITY NAME M 06 In St( -C)tj— <br /> SITE ADDRESS �A /1c) � <br /> -J Street Number Direction �gt��t am ML z C�Zi Code <br /> HOME Or MAILING ADDRESS of Different from Site Address} <br /> Street Number Street Name <br /> CITY STATE ZP <br /> PHONE#1ExT- APN# LAND USE APPLICATION# <br /> b�5 02-2-/ 1 4ci_(�,2_ <br /> PHONE42 E r 80$DI$TRICT LOCATION ODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RE4UESTOR or <br /> I.t� CHECK if SILUNG ADDRESS <br /> BUSINESS NAME � Ped rG i ,yi Sevi t e5 i-no, <br /> Pav# (�o�1-9 33� Ext. <br /> HOME or MAILING ADDRESS 5z ru� f FAX# <br /> ia�9 <br /> CITY K—d 0-4 STATE CA ZP 95-3 6 <br /> 1 <br /> RILL1NG ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same. <br /> acknowledge that all site and/or project specific ENVIRONNIENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> o-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 wort-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: fj� iLl(��t� DaTe•� � )b, <br /> 9 <br /> FROPURT} /$USENFSS ON'NFR❑ OPERATOR/N'IAAAGER ❑ OTHER AUTHORIZED AGENT E Q <br /> !f APPLX.4 VT is 07of the BILLING P.#Rr proof of arttitoriZation fo sigtt is regltirett Ttttr <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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/ste 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. <br /> TYPE OF SERIRCE REQUESTED: (-t 1 7" 7— <br /> COMMENTS:COMMENTS: <br /> ��.Cy-� `�'�ti�'l{�,�, (,cc.,Q. �l.Y� lk��� �-�~r���? �r►-� 3 �, 2��9 <br /> OUIN GOUNTv <br /> SA CNV PONME TMEN1 <br /> t-IEAL�N UEPAR <br /> ACCEPTED BY: C)L EMPLOYEE DATE: <br /> ASSIGNED TO. <br /> 3t O�' <br /> EMPLOYEE#: y <br /> L'L �'( U DATE: <br /> Date Service Completed (if already completed): SEItvICE CODE ct�i P I E; <br /> .2 30 <br /> Fee Amount: 3 !S"T U Amount Paid 1 Payment Date <br /> Payment Type C ;k Invoice# check# Received B <br /> EHD 48-02-025 CJC <br /> REVISED 11/17/2003 SR FORM(Golders Rod) <br />