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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Intermodal Terminal SP Q 000&q l0 V <br /> OWNER/OPERATOR Union Pacific Railroad CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Union Pacific Lathrop Intermodal Terminal <br /> SITE ADDRESS 1000 E Roth Road French Camp 95231 <br /> Street Number Direction I Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1400 '� `~S � • P 1 L a <br /> Street Number Street Name <br /> CITY Omaha STATE NE ZIP 68179 <br /> PHONE#1 Ex-r. APN# 198-200-05, 198-200-16, LAND USE APPLICATION# <br /> ( 402 ) 544-3330 198-200-01, 198-030-28 <br /> PHONE#2 ExT• BOS DISTRICT 3 LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Rosa Chen CHECK if BILLING A4� cN'' <br /> BUSINESS NAME TranSystems PHONE# ExT. CD <br /> ( 510 )612-2282 AR <br /> HOME Or MAILING ADDRESS2000 Center Street, Suite 303 FAX# AN 10 23 <br /> QUIN <br /> CITY Berkeley STATE CA ZIP 94704 0FPgR �NTy <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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 1_._ e_-_,� DALE, 3/3/2023 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is n01 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 <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:Soil Suitability and Nitrate Loading Study Review <br /> COMMENTS: <br /> ItC- 7 ll > La„d (ASQ, 7_55 LS; <br /> ACCEPTED BY: a(�� EMPLOYEE#: DATE: 3 3 Z3 <br /> ASSIGNED TO: �l Z EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: S72-3 P I E: Z&02 <br /> Fee Amount: dP- (OZLf Amount PaidPayment Date 3 3 <br /> Payment Type Invoice# Check# /Sg /17/511'7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />