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SAN JOAQUIN CWTY ENVIRONMENTAL HEALTH DAVRTMENT <br /> SERVICE REQUEST AMEED 0 <br /> Type of Business or Property FACILITY ID# SERVIC QUE T# <br /> 5g"" 6 2 9 1tJ b <br /> OWNER/OPERATOR <br /> PLOT <br /> I I V-Ave-L ILL6 CHECK f BISNG DDR'6SSFACILITY NAME P f f U! `fL- DE C L L.T <br /> SITE ADDRESS 501 A-0,1 c0 1 <br /> Street Number Direction I Street Name city Zip Code <br /> }COME Or MAILING ADDRESS (If jDifferent from Site Address) 40,476 <br /> 0� t6.� A <br /> Z/ /1 <br /> e7 5 C) ��' i P� P-0/0-0 Street Number v�-- Street Name '\ <br /> CITY AV � LLE <br /> STATTIJ ZIP st �� <br /> PHONE#'I (� Exr. APN#1 LAND USE APPLICATfON# <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> (&oil 1 q I <br /> CONTRACTOR./ SERVICE REfQUESTOR <br /> REQUESTOR �,A a VeY 6 R ou P, I n c- CHECK if BILLING ADDRES <br /> sa <br /> BUSINESS NAME " PHONE# �p f L <br /> HOME Or MAILING ADDRESS <br /> qsqs' LUCAS &00-d coq) 49-off©o <br /> CITY j� rl� /t STATE CA ZIP q 3 2-74 <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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Sta1t ar ,STATE a d FEDERAL laws. n <br /> 5/2016 <br /> APPLICANT'S SIGNATURE: DATE: 08/0/0 <br /> PROPERTY/BUSINESS OWNER❑ FR El Au rRORrZEll AGLNT t? i � <br /> I� <br /> OPERATOR/MAN G <br /> IfAppLICANT is mol IeBiLLINGPXRTl: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 env ironmental/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: �� t?-l.� [7 <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#: B ,rr j <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# 77T Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />