Laserfiche WebLink
OCT-07-2005 02 :23 PN TOM 711CKERNAN 1 209 7454792 P. 02 <br /> I- M5 11 ; 08AM KSN -946-0296 N0. 4314 P. 2 <br /> ,AN JOAQUIN BOUNTY ENVIRONMENTAL$SM�TH DEPARTWIT <br /> SERVICE REQUEST <br /> Type oT®uslneea or Prvpettyjl <br /> FACILITY s �-h , . <br /> Agricultu <br /> �tER/OPRUTOR Brods LLC <br /> chmc rt ® <br /> Ftm <br /> AgU11 NAME BroV <br /> &SAD°` 25050Wild Hare Lane A mpo 95220 <br /> FIOME Ot MAIUNO ADDJtM (It DfSite Addrrq) <br /> 1810 N. EI Dorado St., Ste.#7 <br /> CITY <br /> Stockton STATQ CA Z° 95204 <br /> P�Mvsl <br /> 209)464-7658 <br /> PNoele 12exr �'' LAND Uele Ar►uc.no 0`JQ7 �O <br /> 003-100-25 Unassi a ned <br /> e,R. <br /> CONTRACTOR/SERVICE RE UESTOR <br /> Rewu�erott Abby Ricco <br /> c,�erx Irk❑ <br /> 9usimses NAMe' <br /> NO pKow# en_ <br /> Ass 20 7_ <br /> NoIMe yr MAJL1w ADDRiee Fax 0 <br /> em - <br /> Lodl STATX t;A 85240 <br /> A17 LIQ Ac100 U N y,: i, the undarsl ped property or business owner, operator or guthorbled went of same, <br /> acknowledge that all site and/or ProJect SpeoiflC ENViRONIMDrrAL HBAL7H DEPARTMENT hourly charges associated whh this project <br /> or activity will be billed to me or my bndn@se AS ldeAdffed on this form. <br /> I also certify'thnt 1 have prepared this appliostion and that the work to be Performed will be don®la eccordaaco/with 1 SAN 1pAp�u <br /> COUNTY Ordlrrcmee Coded,S1tau,doraLr,$TATH ws, QVC°�/f � �— (" <br /> �, l <br /> AI'PL.iCAM''6 9iQNATUIaE; 1/ <br /> DATzi <br /> ?ROPtRTV/BVAMcss OwNiCR&� / A1v�co OT.� tytgo=W AMWT❑ <br /> "PPLIGNlis.no''he&Lk V—Ed Pr001OfMhorWdontoSign itrequired rUto <br /> RELUK <br /> above site address, hereby authorize the release of , When and all rr applicable, <br /> t lei I,�e owner or operator of tiro propertl•located et the <br /> �U s, geotechnical dada and/or envlroflmental/site seam sment <br /> information to the SAN JoAQu1N Courcy EN VIRONN�ENTA,HEAL1H DEPARTMENT'as soon as it is available enai as same time!t!s <br /> provided to me or my representative. U�t <br /> TYPO OF SERVICE REAIJESiED: y e'i' i / �!. y N♦ �� Q` <br /> / N <br /> SPN'oP oN�14 MENj ENT <br /> ��TN pEPPRSM <br /> AI�t+ROy'ii�wY: <br /> Dst*SOW Cs CoMlplsted (at e, } �It1Pie <br /> 1ItCeCpUL; <br /> 1W A neunt. V. <br /> d <br /> �p Anuount Paha I Nymard DW 0 7 S <br /> "6nt Typ- lcv Q 'I �3 ize.ceap 13� <br /> EHD 4801-028 <br /> REVi9ED"till. SERVICE REQUEST FORM <br />