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Jan 08 09 12:41 p Reliable Petroleum 209-845-8953 p.3 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Go �± �� <br /> OWNER(OPERATOR � `j <br /> _1 a C CHECK if BILLING At IES,rl <br /> FACILITY NAME r <br /> SITE ADDRESS �{ <br /> &N.7] 7r' �— <br /> p��� 1 1. l� � 0.i/l C e:/t qS 3irectiStreet Name C. <br /> HOME Or MAILING ADDRESS (if Different from Site Address) z. coae <br /> CITY <br /> Slreel Number Stree[Name <br /> STATE Zip <br /> PHONE 41 Ex 00) b1s"i APN# LAND USE APPLICATION}E <br /> PHONE#2 Ear. <br /> BOS DISTRICT LOCATION CODE <br /> f ) <br /> REQUESTOR <br /> CONTRACTOR I SERVICE REQUESTOR <br /> ll/�11, <br /> ('', 11 11 <br /> i -v��(� b(kf',/`. -1 �Ij ,� CHECK if RILLING ADDRESS <br /> BUSINESS NAME <br /> cl r a 1 L PC -)It ��y�� S�.r'vl c �s �)�C PHRNE EXT <br /> HOME or MAILING ADDRESS r <br /> `�•? �rLt, lC�f 1'tG J —YDr� FAx <br /> c�?• 9► � [� <br /> STATE (�W ZIP !5311' <br /> BILLING ACICNOWLEDGENTENT: 1, the undersigned property or business owner, operator or authorized anent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DFPAR"17YIENT 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,S-)ATF and FEDERAL lain <br /> APPLICANT'S SIGNATURE: UQ <br /> l DATE: <br /> PROPLRTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHERAui,iioRIZEDAGENT 0 �I 1G'` �t()I- <br /> If APPLIGfA'T is not the BILLING PARTY proof of authorizadayl to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORINATION; When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of anv and all results, geotechnical data and.lor 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. <br /> TYPE OF SERVICE REQUESTED: 1 t� ' l 0 ��if ti S - tr aYMEw IT <br /> COMMENTS: i 1 /r` <br /> JAN 0 8 2009 <br /> SAN�RONMENTAL <br /> HEALTH OEPARTMEWa N <br /> ACCEPTED BY. 1� EmPLOYEE#: DATE: <br /> It <br /> ASSIGNED TO: (1 EMPLOYEE# DATE: <br /> Date Service Completed (if already completed): SERVICE t.OQE: p)E; Z <br /> Fee Amount: / Amount Paid <br /> y 3 s Payment ate c� <br /> Payment Type S invoice# �(GhecR# 0 3 O �k q Received By: <br /> EF42-40-02-025 <br /> REVISED 11117)2003 SR FORM(Golden Rod) <br />