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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ag Commodity Storage and Transfer FA0021499 S2po �-Z LE.(o,3 <br /> OWNER I OPERATOR <br /> Imperial Western Products <br /> CHECKifBILLINGADDRESS <br /> FAc1uTrNAME Same as Above <br /> SffEADDRESS 20500 S. I Holly Drive Tracy 95304 <br /> Street Number <br /> HOME Or MAILING ADDRESS(If Different from Site Address) P.O.Box 1110 <br /> Steet r <br /> CItY Coachella STATE CA Z' 92236 <br /> pHM#1 Ezr. APN# 21216010 LAND USE APPLICATION# <br /> (760) 378-0815 NA <br /> PHm#2 Dcc BOS DISTRICT 5 LOCATION CODE 99 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BIWNG ADDRESS <br /> Jeff Harger <br /> bUSINESSNAME Imperial Western Products (760)378-0815 t4 <br /> HOME or MAILING ADDRESS P.O. Box 1110 FAX# <br /> Cmt Coachella STATE CA ZP 92236 <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 /> f <br /> APPLICANT'S SIGNATURE: DATE: 6/26/13 <br /> PROPERTY/BUSLNESSOWNER[a] OPERATOR/"AGER OTHERAUTHORIZEDAGENT [-]Vice President <br /> If APPLICANT is not the BILLING PARTY.proof of authorization to sign is required 77de <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. f� <br /> TYPE OF SERVICE REQUESTED: 2C 11a��cY� It r M� �QP �a�{U^ (�J'W� <br /> Cohrs: <br /> u ai><u,�u. �J ti�s��� (�c v�¢s3;� F�c,1;�cJ� JUN 2 7 2013 <br /> J SAN JOAQUIN COUN <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: \ r EMPLOYEE#: �Z DATE: <br /> ASSIGNED TO: tl AMS EMPLOYEE#: DATEE: �i,2� 1 <br /> Date Service Completed(if already completed): SER aCOOE: Sa� PIE 14l�a <br /> Fee Amount: bas Amount Paid I I Payment Date �'7 /3 <br /> Payment Type G' invoice# Check# S1 (o Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> RE1/ISED 11/17/2003 <br />