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Street Number <br />Street Number <br />StateCity <br />APN#Land Use Application # <br />Ext.BOS District Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor Maria Medina <br />Ext.Business Name MC Concession Trailers <br />Home or Mailing Address 2716 E Miner Ave B2 <br />City State Zip 95205Stockton <br />APPLICANT’S SIGNATURE: <br />Type of Service Requested: <br />Comments: <br />Employee #:Date:Accepted By: <br />Employee #:Date: <br />Amount Paid <br />Tp^Invoice # <br />SR FORM (Golden Rod) <br />1 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 />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Site Address <br />2 Zip Code____ <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 />40P/ <br />Citv <br />Check If Billing Address LU <br />San Joaquin County Environmental Health department <br />SERVICE REQUEST <br />FACILITY ID # <br />Direction <br />Home or Mailing Address (if Different from site Address) <br />Street Name <br />Zip <br />Check # <br />Type of Business or Property <br />TWTft'oN y <br />Facility Name <br />a™ <br />Date Service Completed (if already oompleted): <br />Fee Amount:^ Q <br />Payment Type <br />Check if Billing Address^] <br />SERVICE REQUEST# <br />Phone #1 , ExT- <br />l& <br />Phone #2 _ . --(g»50) -7-^53 <br />J LO C <br />DC <br />_________________________________ Date: <br />Proper ty / Business Owner C ^Operator / Manager Other Authorized Agent <br />If APPLICANT is not the Billing Party, proof of authorization to sign is required Title <br />AU TIIORIZA TION TO RELEASE INEQRMATION: When applicable, I. the owner or operator of the property located at the <br />above site address, hereby authorize (he release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the San Joaquin Count y Environmental Health Department as soon as it is available and same time it is <br />provided to me or my representative. <br />s ^08^ <br />, p,e' .ii/i? I <br />Received By: dtttr I <br />Phone# <br />( 209 ) 594-0255 <br />Fax# <br />J) <br />CA <br />Service Code: • C’ <br />Payment Date