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SAN JOAQUJN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Equipment Repair 0 �� S4 !j03G <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> A. Teichert & Son, Inc . � <br /> FACILITY NAME <br /> Stockton Shop <br /> SITE ADDRESS <br /> 120 Frank West Circle, Stockton, CA 95206 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P.O. Box 15002 Street Number Street Name <br /> CITY STATE ZIP <br /> Sacramento CA 95851 <br /> PHONE#'1 EXT. APN# LAND USE APPLICATION# <br /> ( 916) 386-3716 193-360-36 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> George Takemorl CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> A. Teichert & Son Inc . ( 916) 386-3716 <br /> HOME or MAILING ADDRESS FAX# <br /> P .O. Box 15002 ( 916) 386-1256 <br /> CITY Sacramento STATE CA ZIP <br /> 95851 <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 or <br /> 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: i�& DATE: March 13 , 2007 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <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 /> TYPE OF SERVICE REQUESTED: / <br /> COMMENTS: RECEIVED <br /> APR 2 0 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: �LQfi-� DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P �� <br /> Fee Amount: cr+ Amount Paid a Payment Date L 2bi V <br /> Payment Type Invoice# Check# 35 f Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />