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SAN JOAQUI160UNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SW- Compost Site FA0023658 s P-00-71 1-�72 <br /> OWNER/OPERATOR <br /> YAYO ENTERPRISE, INC. CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Green Earth Recovery <br /> SITE ADDRESS 20500 1 Holly Drive Tracy CA <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P.O. Box 2643 Street Number Street Name <br /> CITY STATE ZIP <br /> Union City CA 94587 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (510 ) 760-0977 22-160-10 PA- 1600240 <br /> PHONE R ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> YAYO ENTERPRISE INC. <br /> BUSINESS NAME PHONE# ExT. <br /> Green Earth Recove 0977 <br /> - <br /> HOME or MAILING ADDRESS FAx# <br /> P.O. Box 2643 ( ) <br /> CITY Union City <br /> STATE CA ZIP 94587 <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 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: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGE) OTHER AUTHORIZED AGENT D <br /> If APPLICANT is not the BILLING PARTY.proof of authorization to Sign is required Title <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 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 available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: N 9-v3 � v C 0 :U✓1 <br /> COMMENTS: <br /> FEd L 3 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M qwV DATE: 2/&T, t7 <br /> ASSIGNED TO: a>�l� EMPLOYEE M iocyo DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S23 PIE: �N 2 <br /> Fee Amount: I �q S Amount Paid, G Payment Date a 3IR <br /> Payment Type C��_ Invoice# Check# ' Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />