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SAN JOAQL �OUNTY ENN11RONMENTAL HEALT EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CorporationA cc, 5rjL — <br /> OWNER/OPERATOR <br /> Crop Production Services CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Crop Production Services <br /> SITE ADDRESS 1905 N Broadway Avenue <br /> Stockton T95205 <br /> Street Number Direction Street Name Clt 2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3005 Rocky Mountain Avenue <br /> Street Number Street Name <br /> CITY Loveland STATE ZIP <br /> co 80538 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 970 ) 685-3300 143-150-04 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Stephen Meninger CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Rubik Environmental 775 432-0247 <br /> HOME or MAILING ADDRESS FAx# <br /> 320 Flint Street <br /> CITY Reno STATE NV ZIP 89501 <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 HLALTH 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 e work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNT"Ordinance Codes.Slandardr, d FEDER. laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTI'/BGSINESS OWNER❑ P ATOR/ ANAG ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLIC-AIT is not the BILLING PARTY.pr of 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 COUNTI" ENVIRONMENTAL HEALTH DEPARTMEN I'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: <br /> ACCEPTED BY: EMPLOYEE#: � ) l DATE: ` - <br /> ASSIGNED TO: r-]�. EMPLOYEE M 0 j DATE: � <br /> Date Service Completed (if already completed): SERVICECODE: P/E: <br /> Fee Amount: / Amount Paid Payment Date <br /> Payment Type `I Invoice# Che6k# 2_ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />