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Sep 03 09 03.59p Reliable Petroleum 845-8953 p.3 <br /> 6 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> UEST# <br /> Type of Business or Property FACILITY ID# SERYiCE5REO;&7&() <br /> -CA- [ I I? pa! <br /> OWNER 1 OPERATOR-GaiF- F - f I CFIECK if BILLING ADDRESS❑ <br /> FACILITY(NAME C �`r �,�u 'iJ 0, A/ F r <br /> SITE ADDRESS �S l. `I��, C,{u-b 61 V o C) C�Y� �`/y1fS2et� <br /> Street Number Direction <br /> Street Name Ci Ti Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Streek N <br /> CITY STATE ZIP <br /> PHONE#t <br /> EXT. gply# LAND USE AppucxnON# <br /> PHONE EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOI2 vG� CHECK if BILLOY ADDRESS <br /> y!-}-- EzT. <br /> BUSINESS NAMEi1L . PHONES# <br /> ge-lial t Pe, r o 1-e_ul tv, SG��1%' l-1 C a <br /> HOME or MAILiw ADDRESS � f"U n � FAX#-� (�U`�) FLI S'—`��� 3 <br /> CITY <br /> STATE C,Q ZIP <br /> L�u.�L�.cL.�,-� <br /> BILLING ACKNOWLEDGEMENT: i, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site andlor project specific ENViRONmFirTAL HLALTti DEPAWINM-NT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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 FEDERAL laws. <br /> I G <br /> APPLICANT'S SIGNATURE:-(R 6bz4 DATE: <br /> PROPERTY/BI:SINIsSS OwKER❑ ER ATOR/S'IANAGLR ❑ OTHisR AU'moRmEo AGENT E:�O.Q A 1 N, '' <br /> ifAPPLlCAN'T iS not the B&LlNG PARTY,proof of authorization to sign is required Titte <br /> _AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of and• and all results, geotechnical data andlor environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L7F.PARTMr•NT 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 �G�,� c t'x I IV , <br /> COMMENTS: RECEIVED <br /> SEP -3 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> T? oca <br /> ACCEPTED B EMPLOYEE#: DATE: Q <br /> ASSIGNED TO: C-i-y-r R^�- ��(/ s EMPLOYEE N: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P)E: <br /> Fee Amount: -5- 6-0 Amount Paid 'IV 3LF S= Payment Date q 3 0 <br /> Payment Type A Invoi/cye.,,# - Check# Received By: <br /> EHD 48-82-023 e-Z K) C 6�-Sa I SR FORM(Golden Rod) <br /> REVISED 11/1712803 <br />