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SERVICE REQUEST <br /> Type of Business or Properly FACILtrY IO A SERVICE REQUEST <br /> OwxrRI OPSWOR - BAlarG PPrm❑ <br /> John Taylor Fertilizer (Stockton Facility) <br /> NE <br /> John Taylor Fertilizer (Stockton Facility) <br /> 9rEADDREss <br /> 1819 m„rN� o.o„d„ Argonaut sneMw. rYr, sw., <br /> Mailing Address (if Different from Site Addresei <br /> 841 West Elkhom Blvd. <br /> CITY STATE ZIP - <br /> Rio Linda Ca <br /> PHONE11 res. APN# LANDUSEAPPLCAMm1 <br /> 9(16 )991-9813 <br /> PND012 m. SOSDIrrnICr. . - t.aunoxCode. - <br /> ?1619914451 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUEM 13"=Pum <br /> Raracon Engincerine <br /> Btis MS KAYE lalaesl °`� <br /> Ramcon Engineering&Environmental Contracting,Inc. 916-372-7535 <br /> MAuxsAMeass 1PAx1 <br /> PO Box 1026, j 1916-372-4209 <br /> C' West Sacto STAB Ca ZIP 95691 <br /> BILLING ACXNOWLEDGEMENr:L the undersigned Property or business owner,operator a x0oresd agent of same, adowwkege drat as site ardor Dmied sperlx <br /> Pu"HEALTt Sawas EwRCNYERALHEKTi ONSM hourly c ramex assocated wrb nb moiector ach*wa be billed to me ormy b=ness as Wamilled aI tra bmn <br /> I also ardfy M I have prepared to app6abort and to the work b be performed wa be dare mac ==wmt at SAN JOAoue/Ca rY Ommut a Codes,Standards.STATE and <br /> FEDERAL laws. �itA�1.f� <br /> APPUCANT SAMMm: DATE //�,,!/r� V3 <br /> PRCPERTY I BUSINESS OWNER ❑ 1aRliAPrAc,at 0n1E7 AUTH R®AGERr a Operations Manager <br /> aAPacwr a note. ➢ PmoYa/wMaladonrosyebr.w:.e Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When atatdable.I,dte owner or operaterof the proper looted at am above site address,hereby author®the release at <br /> any and ad resu b.geoteLlnial dam anNarenvYommenbYtiie assessnent infumaidw to ere SAN JD=N CUM PUBLIC HE&Tf SERVICES Em as eRAL HEALTH OMWN as soon <br /> w d's available and at the saole tree A'n provided to me or my represemadve. <br /> TYPE OF SERVICE REauumw <br /> 1 <br /> fiDYYERTS <br /> 1 <br /> I <br /> INSPECTOR'S SIGNATURE CONTRACTOR'S SIGNATURE <br /> AFFROVFD er: EaPd_^Y—m1. DATE-' <br /> ASsi m7o: EummEE1: DATE <br /> Date Service Completed (if afready completed) SERVICE CGUE <br /> Fee Amormt Amoum Paid Payment Dab <br /> Psymead Type invoice 4 Check 1 Received By: <br />