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... SERVICE REQUEST EH0067SR revised 09/04/98 <br /> Type of Business or Property FACILITY ID# SERVICE RQEOU T#-73 <br /> Food Distribution Warehouse <br /> OWNER I OPERATOR BILLING PARTY <br /> FACILITY NAME <br /> Carl ' s Jr. Distribution Center <br /> SITE ADDRESS Mellon N,,,, ,�.• <br /> SWIMS <br /> 800 Sonet NumEer d,action <br /> Mailing Address (If Different from Site Address) <br /> CKE Restaurants, P.O. Box 4349 <br /> X <br /> CITY Anaheim, A 92803-4349 <br /> PHONE#T EYT APN# LAND USE APPLICATION# <br /> (20q 823-9251 <br /> PHONE#2 �T BOS DISTRICT LOCATION CAGE <br /> (711 490-3603 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> Jim Thorne <br /> BusiNEss NAME pry 368=6175 <br /> FAX# <br /> MAILING ADDRESS DnCl _ <br /> Cm P o Box 357 STATE CA ZIP 95241-0357 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same,,acknowledge that all Site <br /> and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity Will be billed to <br /> me or my business as identified on this forth. <br /> I also certify that I have preps i applicatio a e to be performed <br /> will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards d F laws. <br /> APPUCANT SIGNATURE: DATE 10/5/98 <br /> AUTHORIZED AGENT r] � t t o r <br /> PROPCitTY/BUSINESS OWNER Ir ElOP�T�/MANAGER ❑ Title <br /> IT APPLIGWI a not the BIILIN(i Pam'proolofauNomarron to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, 1, the owner or operator of the property located at the above site address, <br /> hereby authorize the release of any and all results, geotechnical data and/or envvonmentaitslte assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as It is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> Tank Removal Permit <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER _.s - _. . ❑ <br /> HCA:r.a FCgVf'TY <br /> ENVIRONIJENTAL HLALTIVI fYV SlUN <br /> INSPECTOR'S SIGNATURE: CO <br /> APPROVE9Y: - EMPLOYEE#: DA U <br /> D S L <br /> DATE: <br /> ASSIGNED TO: � � 1 S (� "r I'l EMPLOYEE#: v/ �b 3 ; <br /> j Ll i <br /> Date Service Completed (if already completed): SERVICE CODE: 011 PIE: <br /> Fee Amount K Amount Paid Payment Date <br /> Payment Type invoice k Check# Received By: <br />