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SAN JOAQUL, —'OUNTY ENVIRONMENTAL HEALTI EPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# Park SIC U U S 0 �' 01 OWNER/OPERATOR CHECK If BILLING ADDRESS City of Lathrop FACILITY NAME Manual Valverde Park SITE ADDRESS 15557 Fifth Street Lathrop 95330 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 390 Towne Centre Drive Street Number Street Name CITY Lathrop STATE CA ZIP 95330 PHONE#1 EXT. APN# LAND USE APPLICATION# ( 209) 941-7363 196-240-17 PHONE#2 EXT. BOS DISTRICT ^ LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Fred Allen, Parks Development Manager CHECK if BILLING ADDRESS BUSINESS NAME PHONE EXT. City of Lathrop 20 941-7363 HOME or MAILING ADDRESS FAX# 390 Towne Centre Drive 1209 )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 I 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 laws. APPLICANT'S SIGNATURE: DATE: 6 - /5 - P-7 PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Parks Development Manager If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: E/NT COMMENTS: RECEt v Plan Review for Valverde Park recirculating interactive fountain and restroom/concession building. MAY 15 2007 SAN JOAQUIN COUNTY ENVIRONMENTAL ACCEPTED BY: EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: �> P I E: Fee Amount: try Amount Paid a S Payment Date c> S b'7 Payment Type `/ Invoice# Check# 3 3 Received By: [\f� EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003