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SAN JOAQU COUNTY ENVIRONMENTAL HEAL IEPARTMENT <br /> SERVICE REQUEST AMENDED 0 +V <br /> Type of Business or Property FACILITY ID# SERVICUE T# <br /> -574 c-;, W2 �u n <br /> 15A DOD 60-7 Z' �- z <br /> OWNER/OPERATOR _ v t <br /> PILOT <br /> -Tt7A, 1er ( � /� 1CHECK if BILL�NG i7R SSc.. LJ Lr (�Lr. <br /> FACILITY NAME P <br /> f f C; j ` 7 Z2 /I` lG L— a t j ( ' 6 L L /, <br /> SITE ADDRESS &,l.r (�, d•`-,`Ji,+`-0-i i(Z�t Civ i 5 7J4, <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) r � 5 / A /l <br /> s.5 C)0 4014rl {K-•L)/)'o Street Number a4- Street Name <br /> CITYU1 K ( L L- STATTJ ZIP sl 19 D9 <br /> PHONE#1 I ExT• APN# LAND USE APPLICATION# [ I <br /> PHONE#2E BOS DISTRICT LOCATION CODE <br /> (&Oq) _Sq(." I q I 11 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRES <br /> A��5 �VeY 6 Rove � nG <br /> BUSINESS NAME ,� F PHONE# <br /> lot E., <br /> HOME or MAILING ADDRESSFAX# <br /> gSgs LueAs e�0c �- ( cq) 40.4 o <br /> CITY • a na1D�o �J wo/ if A STATE CA <br /> ZIP q'3 Z-74 <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 ENVIRONMENTAL HEALTH DEPARTMENT 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 prepared • application and that the work to be perfonned will he done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Start ai ,STATE a d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 08/05/2016 <br /> DATE <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAN GER ❑ OTHER AUTRORIZFD AGED[ n(T j YZ G tZ`�2 <br /> If APPLICANT is 1101 L, <br /> BILLING PART),proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORIWATION: 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, gcotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL 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, <br /> COMMENTS: Diesel Tanks #2 &#3, Break out concrete & replace direct bury Fill Spill buckets . <br /> Replace existing drop tubes on Tanks 2 and 3 <br /> Repair Vapor Penetration on UDC 14/15 ��-- <br /> AUG <br /> ACCEPTED BY: EMPLOYEE#: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />