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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Fkwol 10 ,49 6CQ6 oV <br /> OWNER / OPERATOR <br /> C CK If BILLING ADDRESS <br /> FACILITY NAME Tac <br /> SITE ADDRESS 2705 Country Club Blvd, Stockton CA <br /> Street Number Direction Street Name CitV ode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> =StreeNumber Street Name <br /> CITY STATE ZIP <br /> PHONE # I EXT APN # LA USE APPLICATION # <br /> c ) 2 �21u � g <br /> PHONE #2 EXT BOS DISTRICT LOCATION CODE <br /> 11 00 ; <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Walton Engineering, Inc CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT. <br /> Walton Engineering, Inc <br /> HOME or MAILING ADDRESS FAX # <br /> P . O . Box 1025 ) <br /> CITY West Sacramento STATE CA ZIP 95691 <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 an FEDERAL laws . <br /> APPLICANT' S SIGNATURE : DATE : 12� 71 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATO / ANAGER ❑ OTHER AUTHORIZED AGENT ❑ �/ - 1 r <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, 1 , 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 sa sIQt is <br /> provided to me or my representative , �rO An <br /> TYPE OF SERVICE REQUESTED : &. P � <br /> COMMENTS : <br /> sqN J § ? 9 <br /> F/y��gQU/N <br /> 0pq � ry <br /> ACCEPTED BY: 1 EMPLOYEE # : q W DATE : 5 � ' f <br /> ASSIGNED TO : J y; r �l X��t ./ EMPLOYEE M DATE : �1 � ✓ 1 r <br /> Date Service Completed ( if already completed) : SERVICE CODE : i PIE : <br /> Fee Amount: L Amount Paid D� Payment Date / 9 <br /> Payment Type Invoice # Check # Q�O Recei ed By : j <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />