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Jan 14 11 09:56a Reliable Petroleu 2045-8953 p.3 <br /> - IAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE .REQUEST <br /> Type of Business or r� G b C— FACILITY®# SERVICE REQUEST# <br /> 763 <br /> OWNER I OPERATOR ` <br /> CHEGc it RjLuNG ADmEss❑ <br /> FACUff NAME v <br /> sITE aoaREssy 3t I j U e U�'t l�C^ (-�a vi�,.� y TrG�( y -V7 <br /> Stnro!Natuber I Dkwtion S Name Cft Zip Code <br /> HOME or MAILING ADDRESS Of DfHerent from Site Address) <br /> �� I Street Number Steeat Name <br /> c r STATE ZIP <br /> { 15 (`l"-p -? Exr. APN# LAND USE APw.=MCN M <br /> PHONE 12 BCS DISTFWT LOCATIDN CODE <br /> CONTRACTOR f SERVICE REQUESTOR <br /> REQUI:STC}R �,- I'L y� f <br /> dL1�°(� 1 i�✓tr Gi��- — CffECcif !LJMADottess <br /> BUsINESS NAmE <br /> ✓l►' lit �e Gsl est ti, S�-ert,•i'(�es lxi e, y �yS—f58s'(P <br /> Howe or lti1AILll1C AOD i 11�3 o AG rye 5bo t° lu� FAX#'91,�', s,. 5-- E'9 s 3 <br /> CITY STATE CIR Z!P 95-3 4 r <br /> RILLIlIIG ACUNON DGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site an or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project <br /> Or activity will be billed t me or my business as identified on this form. <br /> 1 also certify that I have F I pared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COGN3 Y t7rdfnance C ,Standards,STATE and FEDERAL) <br /> APPLICANT'S SIGN A 'URE: '' 1 %t yL. Dart: I l3 I <br /> PROPERTY/BUSNAPDL C i © <br /> Iff1PPLOPEXU74M/MArtAGER 13OT uLR AuTuo r:ACEKT J4 <br /> IA Isnot.the&LA-6 PARZY.Proof-of wdkorkadon ta.stgn is rapdred Title <br /> AUTHORIZATION LO_REL ASE MORMATION:When applicable,L the owner or operator of the property located at the <br /> above site address, here3y authorize the release of any and all results, geotechnical data and/or environmentaYsite assessment <br /> information to the SAN Jo kqmm COUNTY ENVIitONNEEt""i'AL HEALTH DEPARTMENT as soon as it is available andat the same time it is <br /> provided to me or my r ve, II <br /> TYPEOF SERvicE REQuEmmu V C e-& �iI Gf1'L�y1 i G r'-D 0161 For <br /> CoWeF,ilrs: <br /> 1�- oyl °A- p(U d tuca`-t� ECM VED <br /> JAN 19 2011 <br /> SANH IWIRONMECOU <br /> MY <br /> ACCEPTED EIMPLOYEE P. '1/ _(�/ DATE: �1.1q - 11 DEEA <br /> ASSIGNED TO:M EMp1,0YEE#: o�*� L l� DATE; D <br /> Date Service Completed if already completed): SEmcE CME: I q q P l E: 3 0 <br /> Fee Amount: 3 D Amount Paid Payment 1)zW ( 1.1 I <br /> Payment Type �0 , ' invoice# Chock# i <br /> Received By: <br /> I <br /> REVISED 11/17120Q3 i 4 SR FORM(Golden Rod)5 <br />