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AJ JUIN COUNTY ENVIRONMENTAL HINTH DEPARTMENT <br />SERVICE REQUEST I <br />Type of Business or Property SE <br />FACILITY ID # <br />GDF RVICE REQUEST # <br />OWNER / ®PERFft``rOR Tulare Farrns, LLLP <br />FACILITY NAME TuOa,=-ire Farms, LLLP (was Ace Tomato) <br />$ITEADDRESS 27--91 E <br />French Camp Rd <br />Stree4 Number Direc4ion <br />JJ0IME or MAILING AtniDRESS (If Different from Site Address) <br />CITY <br />PHONE #1 <br />209 ) 235-30-15S <br />PHONE #2 <br />) <br />REQUESTOR <br />BUSINESS NAME <br />EzT. APN # <br />EXT. <br />CHECK if BILLING ADDRESS[] <br />Manteca 195336 <br />STATE CA Zip <br />LAND USE APPLICATION # <br />BOS DISTRICT <br />CONTRACTOR / SERVICE REQUESTOR <br />Carl Wayne Henderson <br />3°� 187 <br />Service Station Testing - SST INC PHONE# <br />HOME or MAILING AVDRESS <br />LOCATION CODE <br />CHECK if BILLING ADDRESS 13 <br />PO Box 31465 FAX# <br />CITY Stockton ( 209 ) 465-4988 <br />STATE CA ZIP <br />95213 <br />BILLING ACKNf7WLEDGEMENT: 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 Ihsve 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 SIC3-'1N1ATURE: <br />DATE: 8/14/13 <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® President <br />1f APPLICANT is not the EILLIN._ G PARTY, proof of authorization to sign is required <br />Title <br />AUT RIZATIOI'*T 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 REQUES. TED: <br />COMMENTS: Remove Tank Gard system and install TSL -300 & 2 ea 420 sensors. <br />ACCEPTED BY: <br />ASSIGNED TO: <br />Date Service Complete --4d (if already completed): <br />Fee Amount: Amount Paid <br />Payment Type I invoice # <br />EMPLOYEE #: <br />EMPLOYEE #: <br />SERVICE CODE: <br />Check # <br />Payment Date <br />DATE: <br />DATE: <br />P/E: <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FnRnn ic„w„_ �__,. <br />