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Sap 16 C8 02:18p Reliable Petroleum 209-845-8953 p.3 <br /> SAN JOAQUJ,� t;OUNTX ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property D FACILITY ID# C pSERVICE REQUEST# <br /> / <br /> OWNER I OPERATOR C C}('rn, ca- a- <br /> CHECKifBILUNGADDRESS� <br /> � <br /> FACILITY NAME <br /> Ala i r\ Sty`c�� � a e(D <br /> � <br /> SITE ADDRESS ) O O e S f`+1-}n S 4 c C--c+ m�l P1+f CCS <br /> f <br /> Street Number Direction Street Name C' i Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOIS DISTRICT LOCATIO ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR R- n <br /> ax r <br /> Y-\ lr-�0-ci- CHECK if BILLING ADDRESS <br /> BUSINESS NAME �,C-\) l nf� 1r(� �Li IM owE y S _ ���/� e<r. <br /> Y" � S�1rVi C.�S .��< C.t� <br /> HOME or MAILING ADDRESSY I rU <br /> Q FAx#�g [� Q S�, ,ao9 ) 8 `1 S3 <br /> GL <br /> CITY �1�).K Q-t -(,— STATE <2 �+ ZIP F j 3 CC <br /> BILLING ACKNOWLEDGEMENT: L the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTI,-IE--N*r hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this farm. <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 FGDGRAL laws. <br /> APPLICANT'S SIGNATURE: �kDL`�� (�, / � � DA'rti: <br /> PROPIiRTY/BI:SINFSSOWNER❑ OPERATORINIANAGER © OTTIFR ATTHORILG)AGEN'r I n <br /> If APPLIC•I,V r is not Me Bttt_/wc PAR-OZ proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORIVfATION: 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/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HFALIH DT.PART VENT as soon as it is available and at the same time it is <br /> provided to me or my representative. 1 uk s —1 "F t7- <br /> TYPE OF SERVICE REQUESTED: Z i'" r C\1 C - g �I , L�N l e 73 a 3 I <br /> COMMENTS <br /> REC'LN\/ <br /> V a s a SEP 16 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: 0,L [ (, ( T/1 EMPLOYEE 2-( DATE: <br /> ASSIGNED TO: Awdu EMPLOYEE# ( DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: 1 PIE: Zia k <br /> Fee Amount: _ 3 ( S- vU Amount Paid �- OQ Payment Date cj <br /> Payment Type ,/1 rJG� Invoice# Cheek#' LA(bs Z Received By <br /> EHD 48-02-025 SFR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />