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SAN JOAQ COUNTY ENVIRONMENTAL HEALT EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Railroad I U o Zito 5,60U65JFL-1L0f-- <br /> OWNER/OPERATOR <br /> Union Pacific Railroad Stockton Yard CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Union Pacific Railroad Stockton Yard <br /> SITE ADDRESS <br /> 833 E. 8th &%Number Direction 8th Street Street Na Stocker On 9Zi Cod <br /> `51 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1400 Douglas Street. Rm 1030 Street Number Street Name <br /> CITY NE STATE 6��79 <br /> Omaha <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (916) 789-5184 t0- 010 _ol� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (626) 890-7100 Bob Rico 01 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEE"T' <br /> United Pumping Service, Inc. P���# 961-9326 <br /> HOME or MAILING ADDRESS FAX# <br /> 14000 E. Valley Blvd. (626) 336-7734 <br /> CITY Industry STATE CA ZIP 91746 <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 /> also certify that I have prepared t ' lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standa ST E and ED S. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ 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 to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: G <br /> COMMENTS: <br /> s <br /> 1 - 2 2- - l y- �joq ?014 <br /> N � /V 1-AUNry <br /> ACCEPTED BY: / r^ EMPLOYEE#: --7 j DATE: f / <br /> ASSIGNED TO: EMPLOYEE#: 1 DATE: <br /> Date Service Completed if already completed): SERVICE CODE: O3 PIE: `-2- j+ <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: LP <br /> E LPL[ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />