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SAN JOAQUIN COUN'T'Y ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST AMENDED 08/05/2016 <br />Type of Business or Prrropperty <br />--IFA <br />FACILITY ID # <br />PHONE# <br />SERVICE REQUEST # <br />�L,E �( 1�A C 11. I'T <br />OOa 6 -7 Z— <br />EMPLOYEE #: <br />OWNER/OPERATOR I T T(ZAdeL <br />Cttgeiz,S <br />LL 6 CHECK If BILLING ADDRESS[] <br />FACILITY NAME I Lc> E —[P— AOC L <br />C�E K) tf i;� V <br />L L 0— <br />SITE ADDRESS i01 <br />.5 <br />"aNumber <br />1 1, <br />Wreellon <br />�.��c I oi3v-- �ZC�� �J <br />&root Nam, <br />iZ1 f O <br />Cil <br />�s 34,(e <br />ZI Code <br />HONE or MAILING ADDRESS (If Different from Site Address) <br />% 0IM6. A20 A <br />oma— <br />S O 0 ,I,R2t�r1 P -0"4-0s <br />met Numbar <br />St � <br />CITY U /� � ILL <br />L E-- <br />$TA IIP <br />! "I <br />PHONE N1 El <br />APN # <br />LAND USE APPLICATION # <br />t ) SQ- & I v <br />PHONE e y _, rI E"BOSDISTRICT <br />(ao <br />LOCATIONCODE <br />CONTRACTO ERVICE RVOITESTOR <br />REOUESTOR �y /' <br />fl , 1�' S C Vey(� 2()/ I' J n iv CHECK if BILLING ADDRESS <br />i/,Y U� `I vv L.� <br />BUSINESS NAME <br />PHONE# <br />HOME or MAILING ADDRESS cYS U L S C— <br />FAY V 500 <br />CITY �gyyr h J OocctynoOM STATE CA Zlp "f -7q <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agm en[[ same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL, HEALTH DEPARTMENT hourly charges associated with this pt' <br />or activity will be billed to me or my business as identified on this form. <br />I also certifythat 1 have prepared application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinmlce Coder, SfaltSTATE a td FEDERAL laws. <br />08/05/2016 <br />APPLICANT'S SIGNATURE:m' , DATE: /� b <br />PROPERTY f BUSINESS OwNERD OPERATOR/MAR GER D OTHEtNAUl HORizEDAGENT / �0/k,T l -z,, -z,, <br />IfAPMCANT is not Ie BILL{NGYARTY proofofanlliorization to sign is required 7vta <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 cnvironmental/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 />nrovided to me or my reoresentative- <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: Diesel Tanks #2 & #3, Break out concrete & replace direct bury Fill Spill buckets . <br />Repair Vapor Penetration on UDC 14/15 <br />c <br />ACCEPTED BY: <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />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 11117/2003 <br />E <br />11 <br />t <br />c <br />fV <br />fiw O <br />rn <br />E <br />11 <br />