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SAN JOAQUIN UNTY ENVIRONMENTAL HEALTH EPARTMENT CrA <br />0 SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAMEPHONE# <br />Service Station Testing - SST INC <br />SERVICE REQUEST # <br />GDF <br />FT��a 0-0 g <br />EMPLOYEE #: -Z 6 •7 0 <br />S P-00 0 %-1,ff <br />OWNER / OPERATOR Tulare Farms, LLLP <br />CHECK if BILLING ADDRESS❑ <br />FACILITY NAME Tulare Farms, LLLP (was Ace Tomato) <br />CITY Stockton <br />SITE ADDRESS 2771 <br />1 E <br />French Camp Rd <br />I <br />P/ E: <br />Manteca <br />95336 <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE CA ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209 ) 235-3055 <br />(—j _ L9 D — q- Z <br />PHONE R EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Carl Wayne Henderson <br />Say 187 CHECK if BILLING ADDRESS® <br />BUSINESS NAMEPHONE# <br />Service Station Testing - SST INC <br />NIvf- <br />SL -300 & 2 ea 420 sensors. �',EF/ J/p® <br />SqN oUG 152013 <br />EN AQU11V <br />HEqcTH )0TAI- Y <br />EXT. <br />209 465-5577 <br />HOME or MAILING ADDRESS <br />EMPLOYEE #: -Z 6 •7 0 <br />FAX# <br />PO Box 31465 <br />( 209) 465-4988 <br />CITY Stockton <br />STATE CA ZIP 95213 <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 <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have 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 SIGNATURE: (L' -e w - �y� DATE: 8/14/13 <br />PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® President <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 <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 />Drovided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: Remove Tank Gard system and install <br />NIvf- <br />SL -300 & 2 ea 420 sensors. �',EF/ J/p® <br />SqN oUG 152013 <br />EN AQU11V <br />HEqcTH )0TAI- Y <br />ACCEPTED BY: // <br />/%„ <br />EMPLOYEE #: -Z 6 •7 0 <br />DATE: <br />ASSIGNED TO: , _ _ <br />EMPLOYEE #: D <br />DATE: <br />Date Service Completed (if already compie <br />it <br />SERVICE CODE: % <br />P/ E: <br />Fee Amount: S - — <br />Amount Pal 375- j�Z) <br />Payment/Date F// <br />Payment Type <br />Invoice # <br />Check # Il3 g <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />