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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTFLDEPARTMENT <br /> 0 SERVICE REQUEST 4 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> BNSF RAILWAY COMPANY Vt 0 p p T2,1`+3 <br /> OWNER OPERATOR ®` 1 <br /> BNSF RAILWAY COMPANY CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> BNSF RAILWAY COMPANY <br /> SITE ADDRESS <br /> 801 Directio DIAMOND STREET STOCKTON 95205 <br /> HOME or MAILING ADDRESS (If Different from Site Address) 740 E. CARNEGIE DRIVE <br /> Street Number Street Name <br /> SAN BERNARDINO STATECA ZIP 92408 <br /> PHONE#1 EXT. APN# 155-320-21 LAND USE APPLICATION# <br /> (909)386-4081 <br /> PHONE#2 ECT. BOS DISTRICT 1 LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR MICHAEL MCLEOD <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME KENNEDY JENKS CONSULTANTS PHONE# EXT. <br /> ( 1 <br /> HOME or MAILING ADDRESS 300 SECOND ST. STE 300 SOUTH FAx# <br /> ( 1 <br /> CITY SAN FRANCISCO STATE CA ZIP 94107 <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 Or <br /> 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 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED:WORK PLAN REVIEW AND PERMIT ISSUANCE <br /> COMMENTS: <br /> ACCEPTED BY:DUNCAN EMPLOYEE#: ,6 Z DATE: 5-11 Z f S <br /> ASSIGNED TO: DUNCAN EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: -TZ-3 PIE: ar{03 <br /> Fee Amount: 3 q a • 0 0 Amount Paid �f 3�d Payment Date I Z / s� <br /> Payment Type �/ Invoice# Check# 3�— Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />