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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUE T Type of Business or Property FACILITY ID # SERVICE REQUEST # Marina Kaiser Commercial Petroleum (209 .887-2639 HOME or MAILING ADDRESS OWNER I OPERATOR CHECK If BILLING ADDREs FACILITY NAME Village West Marina ASSIGNED TO: 7/-)X", ( ) SITE ADDRESS I Embarcadero Drive Stockton 95219 6649 Street Number Direction Street Name Payment Type I / ,1�� y. city Check #�� Zip Code Received By: HOME or MAILING ADDRESS (If Different from Site Address) • - f Street Number Street Name CITY STATE ZIP PHONE #1 ExT. APN # LAND USE APPLICATION # (Zs;) rt51-Is> I PHONE #Z ExT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE IAEOUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME PHONE # EXT. Kaiser Commercial Petroleum (209 .887-2639 HOME or MAILING ADDRESS EMPLOYE FAX # PO Box 1058 ASSIGNED TO: 7/-)X", ( ) CITY Linden STATE QA ZIP 95236 BILLING ACKNOWLEDGEMENT I, the undersigned property or b acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws J APPLICANT'S SIGNATURE: �;�,v„4, ,u PROPERTY I BUSINESS OWNER ❑ OPERATOR 1 MANAGER [9 OTHER AU If APPLICANT is not the BILLING PARTY. proof of authorization to AUTHORIZATION TO RELEASE INFORMATION: When applicable. I. the ov site address, hereby authorize the release of any and all results geotechnical to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it i my representative owner, operator or authorized agent of same, :NT hourly charges associated with this project or will be done in accordance with all SAN JOAQUIN DATE: ? 17- I 1 S iORIZED AGENT ❑ ign is required Time er or operator of the property located at the above ata and/or environmental/site assessment information available and at the same time it is provided to me or TYPE OF SERVICE REQUESTED: COMMENT$/ Gv l S Gtil �t,-U c) PC, s 'e j ACCEPTED BY: ( ?= EMPLOYE #: ice OV DATE: i3/(,. I ` J ASSIGNED TO: 7/-)X", EMPLOYE #: DATE 'N k_ Date Service Completed (if already completed): SERVICE CODE l PIE: Fee Amount: 3c, ( °f Amount Paid �j C� , Payment Date I) I --> c -;—r / +j Payment Type I / ,1�� y. Invoi Check #�� Received By: EHD 48-02-025 07/17!08 ryGb0&.1 r a.v MAR - 9 2015 SAN JOAQUIN COUNTY ENVIROMENTAL H6ALTM DEPARTMENT SR FORM (Golden Rod)