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Jan 24 11 09:10a Reliable PetroleunnA 209-845-8953 p.3 <br /> SAN N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Prop.4ty FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR JJ <br /> LL! S Q f/f�� Cr+Ecrc if aII.UASG ADDRESS <br /> FXAM NAME N) Q.`I <br /> SITE ADDRESS F Q () J -,Al a II 1,1� ! 3 <br /> 1 Street Number Direetlon Street Name G ZI Code <br /> HOME or MAILING ADDRESS If Different from Site Address) <br /> SUeel Number Street Name <br /> CITY STATE ZIP <br /> P}{pNE tN E"T• APN# LAND USE APPLICAnoN# <br /> PAM 112 En'. BOS DISTRICT LOCATION CODE <br /> 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR iay-oho-0- CH—r-CK if BI W NG ADDRE <br /> BUSINESS NAllllEQ,o +l f �troJe.�I/z, Seryl P s -, c, <br /> PHONE <br /> HOME or MAILING ADD S <br /> CITY CI_ �-&'LI -e STATE LP <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 ENvaoNmENTAL 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 j prepared this application and that the woTk to be performed will be done in accordance with all SAN JCAQuiN <br /> CouNTY Ordinance C ,Standards,STATE and FLELlaws.D <br /> APPLICANT'S SIGNA � �' 4 DATE: A� IV / <br /> PROPERTY/RUSUInS OWN R❑ 6IrERA I NIANAGER ❑ OTuER AUTHORXUD AGENT <br /> If APPLIC1.NT is not the BILLING PARTY,proof of ai&horizadan to Sigh 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, he by authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENviRONMENTAL HEALTH DEPARTNIEYT as soon as it is available and at the same time it is <br /> provided to me or my rep esentative. <br /> TYPEoF SERVICE REQUEST : p G ` O � SIP SU 6 tealc S ejl 5C(Z U)cj Fa Imo' <br /> cowrl mr. ��I� 0&� -ti-- 3'�"3 veCA-Er 90� PAYMENT <br /> RECEIVED <br /> JAN 2 4 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: Let ' EMPLOYEE$: ' O A <br /> ASSIGNED TO: IV A 1 0<j EMPLOYEE� �,'�p DATE: <br /> Date Service Completed (if already completed): SERVICE Copia: ici8 P 1 E: <br /> Fee Amount I& Amotlni Paid Payment Date 2 L 1 <br /> Payment Type S Invoice# Ch"k# I 9 C Received By: �C <br /> C-041-119- <br /> EHD 4M2-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />