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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Glassfab Tempering (Rob Gardner Black) CHECK if BILLING ADDRESS X❑ <br /> FACILITY NAME <br /> Glassfab Tempering <br /> SITE ADDRESS 8690W. FLUie Rd. Tracy 95304 <br /> Street Number Direct <br /> ion Street Name I Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 1448 Street Number T Mariana Ct. Street Name <br /> CITY Tracy STATE CA ZIP 95376 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 321-7412 253-210-18 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 11 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak Geo Environmental 209 369-0375 <br /> HOME or MAILING ADDRESS Fax# <br /> 407 W. Oak St. <br /> ( ) <br /> CITY Lodi STATE CA Z'P 95240 <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: AL4 <br /> DATE: Z ^2 2—-2— <br /> PROPERTY <br /> PROPERTY/BUSINESS OWNER OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT El C p N f VL-rA-- <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 /> provided to me or my representative. <br /> I r <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability / Nitrate Loading Study R 7 <br /> COMMENTS: CD <br /> 482 <br /> J 2 <br /> SAN 1021 <br /> ZNItiZ-HV/RQU/N�O <br /> ACCEPTED BY: l - EMPLOYEE#: DATE: a Jai 1 <br /> ASSIGNED TO: S EMPLOYEE#: DATE: p'?Jaa a <br /> Date Service Completed (if already completed): SERVICE CODE: S 3 P/E: d J� <br /> Fee Amount: r:,J Amount Paid (aPayment Date a <br /> Payment TypeNA 0-JVInvoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />