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May 19 10 09:36a Reliable Petroleum 2095-8953 p.3 <br />SAN JOAQULN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REOUEST <br />CONTRACTOR I SERVICE REQUESTOR <br />REouEsToR f <br />Kob 6 I GS t V 1 1. - - CHECK tf $ILLING ADDRESS <br />BUSINESS NAME 0p l�j ,/ j / � ON <br />4 t CLCJ1e- Pe- i ) 1 C'Lt. � f t%1 ( •) }��( pH�v Exr <br />NOME or MAILING A13DRESS <br />CRY / " GL S Cie STATE C fA Zip �S 3 &'-t <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 ENVIRONMENT -AL I-IEALTF DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my husiness as identified on this form. <br />I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUTN <br />COUNTY Odinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />DWrE::+ <br />PROPERTY f BUSINESS OWNERO OPERATOR I A-IANAGL• R ❑ O`T11€R Aur11oRIZED AGENT & <br />/,fAPPLIC;I.NT is not the &!CLING P iRTY: proof of authorizatiotr to sign is required Title <br />AUTHORIZATION 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 environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIKONMENT.41, HEALTH DEPARTMENT as soon as it is available and at the same tine it is <br />provided to me or my representative. i / cT- its - � c- ,T <br />TYPE OF SERviCE REQUESTED: ! 1.GM OV eA rC- •t 1Q 1? Z{. [ <br />i,- i- 1 i : <br />COMMENTS: y' L1L �(4 �� l�"t'� `1'F �/ i1 h <br />C �. t7 Z. �t7 (3 • <br />I /1t' L <br />P�Y <br />RECD <br />vFD <br />SAY 19 2010 <br />JOAQ <br />VlROtiM COUN <br />ACCEPTED BY: L (V 1C l <br />E.AIGiLOYEE #: <br />3 L <br />DATE s- ` ENT <br />/ <br />ASSIGNED T{): .1 �� Q L{ <br />EmF)LOYEE #: <br />;7 <br />DATE: S <br />Date Service Completed (if already completed): <br />SERvcE CODE: l 9 <br />P I E: ce,y <br />Fee Amount: - 3 _ Lr 0 <br />Amount Paid <br />3 4J S— <br />Payment Date <br />!) <br />Payment Type c� Invoice *fteC4t <br /># <br />. <br />Received By: - <br />C >3Y�pC 1r U -V-1 S> t Cr <br />END SED 11/1 SR FORM (Golden Rod) <br />REVISED 11!17!2003 <br />