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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK If ILUW ADDRESS ❑ SERVICE REQUEST # Trucking tlJ 5fee0 OWNER 1 OPERATOR �-r� HE�� 1 V701�&IVIY Estes Express CITY NJ '-X c 4° CHECK if Muigo ADoREss ❑ FActuTYNAME Estes West EMPLOYEE #: a DATE: ho 13 SITE ADDRESS 7611south Airport Way DATE: 12-110 13 Date Service Completed (if already completed)' SER=L Coati: C 3 Stockton 95206 $beat Number D'rectior, Payment Type ,-voice # CfZkocodo HOME or MAILING ADDRESS {If Different from Site Address) Str Rt Number treat Name CITY STATE ZIP PHOK lit ExT• APN 0 LAND USE APPLICATION 0 (209 )982-1841 17705028 P"E #2 Ext. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REauESTOR 4� �A�nn U V► I f f 1 / L: L �. % !� CHECK If ILUW ADDRESS ❑ BusmEs3 NAIVEL" ' -� rvlee- i `0 2013 P ON i Exr. , �7�-Sir l � Hom,q or MAIuNG A DRESS C% �r`�� �-r� HE�� 1 V701�&IVIY F# ( ",) 37.2-A75 CITY NJ '-X c 4° % 17 9V-) / ! STATE 7jP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business Owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENviRONMENTAL HEALTH DEPARTMENT hourly charges associated with this protect or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, LPERATOR and FEDERAL laws. APPLICANT'S SIGNATURE: _ f BATE: %/ /PROPERTY I BUSINESS OWNER 1 ER Q OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY. proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaVsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTtI DEPARTMENT as soon as it is available and at the sante time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: ' !r / l��/%t'-O �� MSN T COMMENTS: C LJ DEC i `0 2013 'AIV JOAQUpy HE�� 1 V701�&IVIY Fxr ACCEPTED BY: moi% i� a Y EMPLOYEE #: a DATE: ho 13 ASSIGNED TO: .✓.�y EMPLOYEE #: IlLr" o l DATE: 12-110 13 Date Service Completed (if already completed)' SER=L Coati: C 3 I PIE: Fee Amount: Amount Paid 3 7,S--. O0 Payment Date 1,2 jtj 1 Payment Type ,-voice # Check # (mil � Received By: EHD 48-02-025 SR FORM (Golden Rod) 07117108