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SQ <br /> SERVICE REQUEST <br /> r _ <br /> Type of Business or Property FACILI Y ID 9 SERVICE REQUEST�G <br /> Food Processingand Packaging -- � �} <br /> OWNER/ OPERATOR <br /> CHECK it BI LING A00 E55 <br /> FACILITY NAME MUSCO OLIVE PRODUCTS, INC. <br /> SITE ADDRESS <br /> 17950 r N 6 len Via N1C010 Meet Name __—_I__IYne I Suite4 '• <br /> St..4s3—i+�LSL�..RJtssS. . <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CITY STATE zip <br /> Tracy CA 95376 <br /> PHONE#1 FXT• APN LAND USE APPLICATION 14 <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> • ( I r <br /> CONTRACTOR ! SERVICE REQUESTOR <br /> REQUESTOR <br /> l Charles R: Sneaffer CfiECKtfBILLING ADDRESS <br /> ❑ <br /> BUSINESS NAME PHONE# EXT. <br /> FOODPRO INTERNATIONAL, INC_ ( 209) 943-8400 <br /> Hone or MAILING ADDRESS FAX If i <br /> 6 So. E1 Dorado ST. , Suite 401 ( 209) 946-1753 <br /> CITY Stockton STATE CA ZIP <br /> 95202 <br /> BILLING ACK,NOWLEDGI;MI, the undersigned property or business owner, operator or authorized agent of same, { <br /> acknowledge that all site and/or project specific PUBLIC fiCALTH SERviCES ENVIRONMENTAL 1IEALTII DIVISION hourly charges � <br /> associated with this project or activity will be billed to nue or my business as identified on this for-nu. <br /> I also certify that I have prepared this application and that the work to be perfomic will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: /' DATE: <br /> PROPERTY/BUSINESS OWNFR OPERATOR/MANAGER OTHE AUTIKOR1ZED AGENT <br /> 1fAPPLIC.4Nr is not the t .+ proof of authorization to sign is required Ttris <br /> 1 TIT01217 TTQN TO RFT EA F : Wltcn applicable, T, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all resuits, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTH Sr,-RVICE:S ENVITtONrrlt:NTAL FiEALTH DIvisioN as soon as it is available and <br /> at The same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: s PAYMENT <br /> EIVED i <br /> COM6tENT5: .. a RAS AAJUVn"1 R17- IjI.+ ' <br /> ��„� �� �Recr�.��xna R�v-r� �v..r.,�,/ ,v IJV � . <br /> 9 AWNS ARAB to C'iA+�Ckx�r.e,� w4 De Nor cxs6 , <br /> 10•zb9? ao9A40114E uFar17Y <br /> PUBur + +kTH s <br /> /o-2t«9�— SRX R�c��NrD Assdl,�trr+G. G.Ra.Ivpaue7%R 4,aT'h MTiFp. � F404&vvl�rll <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: " V <br /> APPROVED BY: EMPLOYEE t/: DATE: <br /> r <br /> ASSIGNED t0: EmPlOYEE✓a: // DATE: <br /> Date Service Compte 0 ('If already Completed: SERVICE CODE: P 1 E: <br /> FP .. <br /> unt: Q Amount Paid Payment Date Type Receipt# Check 9 Received By: <br /> SltliliQrev.Juc 7/1/1799 <br />