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SAN JOA(*T COUNTY ENVIRONMENTAL HEALODEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gasoline S�a-fiien _3q Z21fA <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> CH EvlzoN p>~bt7UGTS G6• <br /> FACILITY NAME* 20 I 1 (o'7 Ave,SITEADDRESS 125.+ YDSMite A • r'1-anfi-cGQ '5 C 3<o <br /> Street Number Direction Street Name CI Zi Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 <br /> EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#TT BOS DISTRICT LOCATION CODE <br /> 11 <br /> ( ) <br /> I SERVICE REQUESTOR <br /> REQUESTORA ae � / ;^n�n b / Q_D�. Her. <br /> CHECK If BILLING ADDRESS <br /> (7 a t (' r. <br /> PHONE# Er. <br /> BUSINESS NAME � In G, <br /> RNL Des n &fbUP 6125 <br /> HOME Or MAILING ADDRESS FAX <br /> 1340 Arnold Drive. Suite �ld (4125) 313 - 1?01 <br /> CITY STATE CA ZIP '14563 <br /> t1�r1'i nc _1'!-J <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator o authorized agent o same <br /> acknowledge that all site and/or project Specificecific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated protect <br /> or activity will be billed to me or my business as identified on this form. <br /> I 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 /> APPLICANT'S SIGNATURE: DATE: ' ZJ.1 �u� <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR G ❑ OTHER AUTHORIZED AGENT IR f b1 Ge. 1"I2I=Aer <br /> If APPLICANT is not theBILLINGPIR TY.proof ofauthorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMA'T'ION:When applicable,I,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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availa�P�t.�, ve time it is <br /> provided to me or my representative. R �_1 <br /> TYPE OF SERVICE REQUESTED: Repair Rte�y.t rof it <br /> /Fign � hac <br /> COMMENTS: Plan r' eGk -for 5 ill �n�'2irtr►+ehfi reFlace-rn4r%+. SEP 4 04 <br /> P �'hiv`'OAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: C- �AA� EMPLOYEE M 6 i j.Z 1 DATE: 'Z y G <br /> iL-1 �' n <br /> ASSIGNED TO: J uN �L u� EMPLOYEE#: P3 i 7 DATE: -> ("L— <br /> Date <br /> % ,Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: c Amount Paid Payment Date a P <br /> Payment Type Invoice# Check# D R ceive By: n� <br /> EHD 48-02-025 SR FORM(Golden Rdd <br /> REVISED 11/17/2003 <br />