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Dec 08. 10 02:12p Reliable PetroleumA 209-845-8953 p.12 <br /> AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Type of business or Pru perty <br /> SERVICE REQUEST <br /> 1 ACRITY ID# SERVICE REQUEST# <br /> OtNNER!OPERATOR <br /> 7- :�=r -S'200�'Ico <br /> )6'A Aa a- CHECK if BivauG AnORESS C� <br /> FAcam NAME <br /> SrrF,ADtu&ss H00 <br /> oV,t� <br /> sbcat N mbar otreetioq !S 3 <br /> HomE or MAWNG ADDRESS Of Diflenent from Site Address) sneer Name cone <br /> Cmr Street Number Shat Nmrte <br /> STATE ZIP <br /> P}iONEV Ezr. <br /> *Dry 1 Q 2-5- f 1 �w$ L—USE APmCAttax# <br /> Iyit�1�Z eR. <br /> ( ) BIOS D>5-rptCr tocATioN cone <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> e 1�1 V 1 V- C ECKUMLLINGADDREssL� <br /> BusiwEss NAYE �_1. ` '�- <br /> gErr. <br /> HoeAE Or MAAiL1ttG ADORES FAX# <br /> CrTv a� STATE ZIP ys Cv <br /> BILLIING ACKNOWL DGE- ENT: I, the undersi ed Property 3 / <br /> gn p perty or business owner, operator or authort'zt of sante, <br /> aclmowledge that all site d/or project specific EN-VIRONMENTAL HEALTH DEPARTMENT hourly charges assodatect wltn is pl'i'a <br /> or activity will be billed to me or my business as identified on this form- ''nn <br /> DEC <br /> I also certify that I have this application and that the work to be performed will be done in accordance with allOSr+�IE��tt�3lta <br /> COUNTY Ordnance COdes,,Standards,STATE and FEn L laws. SqN <br /> � Fn�O'q�lllN <br /> APPLICANT'S SIG NA DATE: '�� �i C MEN7-A Nn' <br /> PROPEirrV/0usufPSSQyyH Q OPERATOR Il14ANAGER ❑ OTtreRAUTHORIMMACENT <br /> IfAPPLl is not the Blf-.lrvG PARTY Proof of crhorizabont to sign if required Title <br /> AUTHORIZATION TO WLEASE INFORMATION: When applicable,L the owner or operator of the prdDerty located at the <br /> above site address, hereEy authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JO QUIN COUNTY£NVIRONTvIFNTAL HEALTH DEPARTMENT as soon as it is available and at the Barrie time if is <br /> provided to me or my repr tive. <br /> TvaEt)FSEIZvicElk-4uEsrED TLS S b ,�jL CcJ <br /> AccEFrED BY: ----- y EMA!oYEE DATE: <br /> AssiGwen TD: E.MPw�#-. <br /> ` ) DATE: <br /> Date Service Completed ( alrea completed): SEME CODE PIE: <br /> Fee Amount: ( v Amount Paid <br /> 3�� -- Payment#Data a <br /> Payment Type Invoice# chow# /� ReCeiVed fay: <br /> E}!D 48-02-025 l3 <br /> C�� <br /> REVISED 11117rzom SR FORM(Golden Rod) <br />