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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT NOV 19 2015 <br /> SERVICE .REQUEST IRONMENTAL <br /> f Business ar Property FACIlITY ID# SER1Mt��Concrete Man€acture - OW�C1CC)[T:YPe <br /> R/OPERATOR <br /> John Bertao CHECK if BILLINGADDRESS� <br /> FACILITY NAME Knife River Corporation <br /> SITE ADDRESS 655 <br /> Qlatewe'r <br /> • �`�`� Stockton 95205 <br /> StrBe Number i n Na e <br /> HOME or MAILING ADDRESS (If different from Site Address) C e <br /> > I` Street Number ! <br /> CITY (, Street Na e <br /> S7 TE zip t �( <br /> Exr• APN209f9 ' r <br /> LAND USE APPLICATION# <br /> 7b 7 I� <br /> PHONE#2 Exr. <br /> '•�' DOS DISTRICT <br /> LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> :l <br /> REQUESTOR Carrie Miller <br /> CHECK ff F3ILUNG ADDRESS <br /> BuslNEssNANRE Elite IV Contractors PHONE# Exr. <br /> HOME or MAILING ADDRESS 209 <br /> 2535 Wigwam Dr FAX# <br /> ( 461-6342 <br /> CITY Stockton STATE CA ZIP 95206 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/or project specific ENVIRONMENTAt_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 /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQt.1tN <br /> COUNTY Ordinance Coates,Standards,STATE?and FEDERAii.laws. <br /> APPLICANT'S SIGNATURE: C,.^r&4.ee, 7��, <br /> DATF,: <br /> PROPERTY/BUSINESS OWNER© OPERATOR/NIANAGER l] OTHER AUTHORmLD AGENT1 pffice Manager _ <br /> If.4PPL ICA NT is not the BIL I I N C PARTy proof of autit orizatiotr to,sign is required Ttrte <br /> AI)THORIZATION TO RELEASE INFORMATION: When applicable,1,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 environmental/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: `7 - Li tx(l� D 1,k( .-at,iJ LA-, I ,�Y <br /> COMMENTS: "i <br /> *O;e4? <br /> O.1w <br /> ACCEPTED BY: EMPLOYEE#: DATE: l 7 Fw <br /> ASSIGNED TO: ,v EMPLOYEE#: DATE: I i <br /> Date Service Completed (if already completed): !f �� SERVICE CODE: l P!E: Z.50 <br /> Fee Amount: Amount Pai B.dC� Payment Date /( <br /> Payment Type / Invoice# Ch # ZZ Rec ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />