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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY IID # <br />SERVICE REQUEST <br />Truck Stop <br />lX C? <br />�x <br />�# <br />� u, 0(f/ <br />OWNER/ OPERATOR <br />20,7 <br />775 358-4403 <br />HOME or MAILING ADDRESS <br />SIgN JO,gQUIN <br />FAX # <br />CHECK if BILLING ADDRESS <br />Love's Travel Stop <br />( 775) 358-4411 <br />CITY Sparks <br />STATE NV ZIP 89431 <br />FACILITY NAME <br />0, <br />EMPLOYEE#: <br />DATE: <br />Love's Travel Stop <br />ASSIGNED TO: <br />( <br />EMPLOYEE #: <br />DAIE: <br />SITE ADDRESS 1553 <br />Colony Rd <br />Ripon <br />Fee Amount: 4 I <br />95366 <br />Street Number <br />Direction <br />Payment Type - . <br />Street Name I <br />Check # f_. 051 D `� <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />SAME <br />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT _7 <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />Keith Perks <br />COMMENTS: <br />BUSINESS NAME <br />JAN 17 <br />PHONE If EXT. <br />L.A. Perks Petroleum Specialists <br />20,7 <br />775 358-4403 <br />HOME or MAILING ADDRESS <br />SIgN JO,gQUIN <br />FAX # <br />765 E. Greg St <br />( 775) 358-4411 <br />CITY Sparks <br />STATE NV ZIP 89431 <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 />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 />APPLICANT'S SIGNATURE: DATE: 1116117 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ® Director <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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />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 <br />my representative. p <br />TYPE OF SERVICE REQUESTED: os <br />RE <br />COMMENTS: <br />JAN 17 <br />20,7 <br />SIgN JO,gQUIN <br />JiOAP <br />��R <br />EP TME 1Y <br />ACCEPTED BY: <br />U <br />0, <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED TO: <br />( <br />EMPLOYEE #: <br />DAIE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: j q <br />PIE: <br />Fee Amount: 4 I <br />Amount P' l <br />7 e> Z:) Payment Date <br />f I <br />Payment Type - . <br />Invoice # <br />Check # f_. 051 D `� <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />