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SAN JOAQUCOUNTY ENVIRONMENTAL HEALTHOPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS® FACILITY ID # COMMENTS: Repair OMNTEC ATG as needed. SERVICE REQUEST # GDF 0 HOME or MAILING ADDRESS '1400&/&'?0 OWNER / OPERATOR PO Box 55105 DATE: ! Z3 /10 Phil CITY Stockton CHECK if BILLING ADDRESS FACILITY NAME Country Club Food & Fuel P JE: Fee Amount: ?� (DCp -00Amount SITEADDRESS 1856 I Country Club Blvd I Payment Type /' Invoice # Stockton 95204 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE CA ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # ( 209 ) 662-0952 PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS® BUSINESS NAME APEC COMMENTS: Repair OMNTEC ATG as needed. PHONE # EXT. ACCEPTED BY: �� 209 1 943-3000 HOME or MAILING ADDRESS ASSIGNED TO: FAX# PO Box 55105 DATE: ! Z3 /10 ( 209 ) 943-3003 CITY Stockton STATE CA ZIP 95205 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 project 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, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: C-� [.. H� DATE: 12/22/10 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGES OTHER AUTHORIZED AGENT if APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: �% 7-0 / /"J Cl— 4-15 A+ f COMMENTS: Repair OMNTEC ATG as needed. P RECEIVED DEC 2 3 2010 SAN JOAQUIN COUNTY ENwr-ALVIRONMENTAL DEP�tMENT ACCEPTED BY: �� EMPLOYEE #: O3 Z DATE: C-0 ASSIGNED TO: EMPLOYEE #: +('016 DATE: ! Z3 /10 Date Service Completed (if already completed: SERVICE CODE: [, P JE: Fee Amount: ?� (DCp -00Amount Paid 3 bb Payment Date �'L (� Payment Type /' Invoice # Check # O ':� b Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 O1(