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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> INDUSTRIAL PARK <br /> OWNER/OPERATOR DAVID, GARRETT & RANDALL RAJKOVICH CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME BLOSSOM INDUSTRIAL PARK <br /> SITE ADDRESS 3263 CHEROKEE ROAD STOCKTON 95205 <br /> Street Number I Direction I Street Name c1tv Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) PO BOX 4331 <br /> Street Number Street Name <br /> CITY STOCKTON STATE CA ZIP 95204 <br /> PHONE#1 EXT_ APN# LAND USE APPLICATION# <br /> (209)993-8302 132-070-10 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 00 Z `C; <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR DAVID, GARRETT& RANDALL RAJKOVICH CHECK if BILLING ADDRESS <br /> CL <br /> BUSINESS NAME BLOSSOM INDUSTRIAL PARK PHONE# EXT. <br /> 209 993-8302 <br /> HOME or MAILING ADDRESS PO BOX 4331 FAX# <br /> ( 925)262-4646 <br /> C1TY STOCKTON STATE CA ZIP 95204 <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 /> I also certify that I have prepared this app ' ead the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,SL laws. / <br /> APPLICANT'S SIGNATURE: DATE: -7 <br /> PROPERTY/BUSINESS OWNER❑ OP TOR/nI 1NAGER ❑ OTHER ALiTHORIZED AGE\,� 7 �i� <br /> If APPLIC_4:vT is not the BILLIAG PART/',proof 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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 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: ujA M <br /> COMMENTS: l0 ` RECEIVED <br /> /� /Y IZ1�/i t, RECEI ----' <br /> tz-7 t /r > cd b �` 24 2014 <br /> A AUe(QUIN <br /> 2014 <br /> P' <br /> A ENV ROMENT)JOAQUIN COU TY SAN JO COUNTY <br /> ENVMENTAL <br /> ACCEPTED BY: M . �"9-1 —" EMPLOYEE#: 2�-7 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> L <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: 17/0 Amount Paid Payment Date a <br /> Payment TypeInvoice# Check# Received tfi <br /> y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />