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SERVICc' REQUEST FACILITY iD # RECORD ID # INVOICE # CEN GD bi? Revised 3/230.3 FACILITY NAME San Joaquin County Mosquito & Vector Control Distict BILLING PARTY =/ SITE ADDRESS 7759 South Airport Way CITY Stockton CA zip 95206 OWNER/OPERATOR John Stroh BILLING PARTY Y / ON � CRA San Joaquin County Mosquito & Vector Control Districpgqel 2t 09 )_282-4&75 �J ADDRESS 7759 South Airport Way PHONE 02 t 800 ) 300-4675 CITY Stockton STATE CA # ffLand Use Application N zip 95206 71 BGS Dist Location Cade CONTRACTOR and/or SERVICE RECUESTOR Barry E. Edmiston BILLING PARTY O / N DBA Ramcon Engineering & Env. Contracting, Inc. PHONE in C 916 > 372-7535 NAILING ADDRESS 3751 Commerce Drive FAX # ( 916 ) 372-4209 CITY West Sacramento STATE CA Zip 95691 BILLING ACKNOWLEDGEMENT. I, the adersigned ower, operator or agent of surae, ackpiowtedge that all size and/or project specific PNS/M hourly charges associated with this facility or xtivity wilt be frilled to the party identified as the BILLING PARTY on Page I of this form. 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 COUNTY Ordinace Codes and Standards. State ad 0*aL Laws_ APPLICART'S SIGNATURE Administrative Assistant Date- 4/13/00 AUTHORIZATION To RELEASE INFCRMATICN: In addition to the above, when applicable, 1, the osier, operator or agent of 6 , of the Property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or ervironmentaL/site assessment infornutian to SAN "=IN raaTT PUBLIC NEALTH SERVICES ENVIRONiaWAL HEALTH DIVISION as soon as it is available and at the sane time it is provided to me or of representative. - Nature of Service Re.Iuest: ! serd+ce Code Assigned to Date Service Canpleted Employee d Further Action Required: T / N Date _jam Fee AMOUnt Amount Paid Date of Payment Payment Type Receipt At Check R Recvd ey RERS �!�_ SUPV ACCT 1 �_/_ iUNIT CLK ^/ /