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rACiLflr ra nt ,�y^oRo Io :x 'F�IYOtCE x <br /> LrACILIVY RA HE Concrete Inc. o1LLINo PARTY / tl <br /> SITE ADDRESS 749 S. Stanislaus St. <br /> LStockton, 95206 <br /> CiTY CA ZIP <br /> UIER/OPERATOR Same as above <br /> 81LL1N0 PARTY <br /> RRA PHONE ffl (.?,09 ) 283---6565 <br /> �,� I [ <br /> ADDRESS - PNONt rY2 i 2n9 .) 983-.657J ; <br /> STAi� ZIP <br /> APN Lend Use Application fl i <br /> DOS Mat Location Code <br /> UDHTRACiOR Ana/or �iJimThorpe Oil Inc. <br /> VICE REDt1ESIOR , r S1LLrNO PARTY Y / N <br /> DBA <br /> Rich—Mart Construction PHONE qtr c 20 —)-462—458.1. ! <br /> 14AILIHo ADDRESS P.O. BOX 357 FAX / (2_)'£Fsl3..MS1; <br /> LCiTY Lodi, STATE CA ZIPL <br /> RlLttHO ACKHMEDCEHENTI I, the undersigned owner, operator or agent of same, acknowledge that all alto and/or project specific I. <br /> rlt$4110 harrty chargee ansoclated with this futility or ectivity will be billed to the party Identified as the liLLiNO PARTY on i <br /> Inge 1 of this form. <br /> i <br /> L I r►tso certify that 1 have prepared this application end that the work to be performed will be done In accordance with all SAM <br /> JOAQUIN COUNIY ordinance Codes a rds, State and Federal laws. <br /> LAPPLICANi'S SIGNATURE t <br /> • t '7 Q I <br /> Title: Date., <br /> LUI AORIiATIOH 10 RELEASE INFORHA11ONt In addition to the above, uheniappticabte, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> erwirormentet/site assessment information to SAN JOAQUIN COUNTY PUDLIt HEALiH SERVICES ENVIROWERIAL HEALTH DIVISION aA soon as <br /> LIt It available and at the same time it is provided to n+e or Dry representative. <br /> Nature of Service Requests service Code <br /> LAssTgrmd to Employee s Date / / <br /> Date Service Cmrt eted / / Further Action Requlredt Y / N PRMRA1l E1 HENT <br /> • I <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt I check D Recvd By <br /> i <br /> REHs <br /> suPv �.I I ACCT ,�,,.•I I uNrT CLX _l •�_ l . . <br /> L <br />