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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Frontline Industries CHECK If BILLING ADDRESSO <br /> FACILITY NAME KW Defense <br /> SITE ADDRESS 1640 N. Broadway Ave. Stockton 95205 <br /> Street Number Duecnon I Street Name City MID Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EX. APN# LAND USE APPLICATION# <br /> (209 ) 251-9931 143-250-12 PA-1700271 <br /> PHONE#2 EM• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS� <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. <br /> 1209 )369-0377 <br /> CITY Lodi STATE CA ZIP 95240 <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 this application and that the work to be performed will be done in accordance with all SAN JoAQu[N <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE; "'41 <br /> PROPERTY/BUSINESS OWNER❑ `/c OPERATOR/MANAGE OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PAR TP 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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and a e same time it is <br /> provided to me or my representative. L P---� � <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study ien <br /> COMMENTS: �. ! / r/ - y ?018 <br /> HEAL H�ONMEI NTUN <br /> is TY <br /> EPART NT <br /> ACCEPTED BY: IM Il EMPLOYEE M DATE: <br /> ASSIGNED TO: �1D EMPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: y P/E: <br /> Fee Amount: i .Amount P �,Oy. D Payment Date Z/ lO <br /> Payment Type cle Invoice# Check# IjO3 Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />