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SAN JOAQUI ;OUNTY ENVIRONMENTAL HEALTH XARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # REQUEST # restroom/concession building. BUSINESS NAME City of Lathrop /SERVICE S lid O s o� U Z Park 941-7363 EXT. HOME or MAILING ADDRESS OWNER / OPERATOR CHECK It BILLING ADDRESS City of Lathrop DATE: 0-4 FACILITY NAME )941-7219 Manual Valverde Park STATE CA SITE ADDRESS 15557 Fifth Street I Lathrop 95330 Street Number Dlracdon Street Name Payment Date city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Check # 3 `31{3 1 Received By: � 390 Towne Centre Drive Street Number Street Name CITY STATE ZIP Lathrop CA 95330 PHONE #1 E1rr• APN # LAND USE APPLICATION # (209) 941-7363 196-240-17 PHONE #2 En. ( ) BOB DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS Fred Allen, Parks Development Manager restroom/concession building. BUSINESS NAME City of Lathrop PN"109 N 941-7363 EXT. HOME or MAILING ADDRESS FAX# ACCEPTED BY: 390 Towne Centre Drive DATE: 0-4 (209 )941-7219 CITY Lathrop STATE CA ZIP 95330 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 l 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 F ER lawp. APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Parks Development Manager lfAPPLICANT 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: Pp' Ep COMMENTS: Plan Review for Valverde Park recirculating interactive fountain and .pY 1 5 2001 restroom/concession building. M SAN ENVIRONME MEff DEPAItf HATH ACCEPTED BY: EMPLOYEE #: DATE: 0-4 ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: S �j� P 1 E: 6 Fee Amount: lP Amount Paid '� , Gb Payment Date Payment Type Invoice # Check # 3 `31{3 1 Received By: � EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003