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A <br /> SAN JOAQUIN COUNTY ENMONMENTALHBALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property R FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK If SLUNG ADDRESS❑ <br /> FACILITY NAME Q _ .a,', A,t, S <br /> SVIE <br /> t at Numbs Dlnciton • • � «eel Arne 4 :� ZipCode 1 <br /> HOME or MAILING ADDRESS (it Different from Site Address) 1 <br /> S«oef NumberSirmt <br /> CITYGd,TI. .I-._t T TE ZIPcr <br /> #) ��� DIN <br /> APN# LAND USE APPLICATION <br /> �q # <br /> PHONE42 EXT. DOS DISTRICTLOCATIONCODE I <br /> ) i <br /> I <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Jeff Nelson CHECKIMILLINGADDRESS13 <br /> BUSINESS NAMEEXT <br /> Shields, Harper & Co P"�"'�� 377-6991 <br /> HOME Or MAILING ADDRESS FAX# <br /> 4591 Pacheco Blvd I ) <br /> CITY Martinez STATE CA zip 94553 <br /> BILLING ACKNOWLEDGEMENT: I, die undersigned property or business ornery 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 Cortes,Standards, n laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> I <br /> PROPERTY/BUSINL55 OWNERD OPERATOR/MANAGER ❑ Grain AUTNORIZHD AGENT® j <br /> IfArruCdNrlsHaflhe/3LUNGP,tKr'r.proofofartfher7Za!lonlosignlsregrdred TI fie E <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner,or operator of the property locatedt�3q yM�'•A� I <br /> above site address, hereby authorize the release of an and all results, geotechnical data and/or environmantallsite arse i <br /> information to tite SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM13NT as soon as it Is available and at the same time i <br /> provided to me or my representative. _ _ JUAlAi �i�FQ <br /> TYPE OF SERVICE REQUESTED: Cold Start Veeder Root TLS-350 jV 91015 <br /> COMMENTS; This is required to change the CDIM to EDIM for a new Cash Register Sys y90ty oo i <br /> oFOA Al,- <br /> .41,t4fin' <br /> j4 y <br /> i <br /> i <br /> i <br /> ACCEPTED BI': EMPLOYEE p: DATE:rQ(P (S <br /> ASSIGNEDTO: Gam. Ri EMPLOYEE#: DATE: o(P (S <br /> Date Service Completed (if already completed); SERWACODE:.C�-U� PIE: 23rd <br /> Fee Amount; '7j�Q-oil Amount Pai 3 0 Payment Date I <br /> Payment Type Invoice# Check0 X3513 so vedBy: j <br /> EHO 4"2-026 SR FORM(Golden Rod) I <br /> REVISED 11/17/2OD3 <br />