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Dec 07.10 02:43p Reliable PetroleumA 209-845-8953 p.3 <br /> AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK itBILLING ADDRnS� <br /> FACILITY NAmE <br /> SITEADDRESSJ"` <br /> 110 0 r-e <br /> Street N mber Direetion Street Name Zi Code <br /> /5V 3 -34., <br /> C <br /> HOME Or MAILING ADDRESS (If Dfffer�ertt from Site Address) <br /> Number Stre9t Street Name <br /> l±ll Y STATE Zp <br /> PHONE#1 EKT. APM# LAND USE APPLICATION# <br /> PHONE#2 E>T. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Rk 1Ako-r <br /> CHECK if PILING ADDRESS <br /> BUSINESS NAME PHONaoE#y EXT. <br /> HOME or MmuNG ADD RE,4 FAX# <br /> ( q Sys- F-/s3 <br /> CITY 1 STATE zip <br /> KILLING ACICNOWL DGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENvIRONMENTAL HEALTH DEPARTMETIT 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 Frepared this application and that the work to be performed will be done in accordance with all SAN JOAQUrN <br /> COUNTY Ordinance Codm,Standards, STATE and FCo L laws. <br /> APPLICANT'S SIGNA + /� . /� DATE: )aL-1 <br /> 1 <br /> PROPERTY/BUSINESSOWN R❑ OPERATOR/MANAGER ❑ OTHERAUTHORIzEDAGENVTEI r <br /> IfAPPLICAVris not the BILLING PAR 7Y proof of authorization to sign is required Title <br /> AUTHORI7.ATION 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 envi[onmenW/site assessment <br /> information to the SAN J QU"N COUNTY"ENvrRONMENTAL 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 TLS " si /1 <br /> < -/u— <br /> ACCEPTED <br /> SSC- LLJ <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#_ DATE <br /> Date Service Completed if already completed): SERVICE CODE: PJ E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# <br /> Received By: <br /> FHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />