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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 9DC �S-Y,3S- <br /> OWNER/OPERATOR <br /> WATERLOO FOOD & FUEL CHECK if BILLING ADDRESS <br /> FACILITY NAME WATERLOO FOOD & FUEL <br /> SITE ADDRESS 3032 WATERLOO RD STOCKTON 95205 <br /> Street Number Direction Street Name CI ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 44 CASTLE HILL CT Street Number Street Name <br /> CITY ROSEVILLE STATE ZIP <br /> CA 95678 <br /> PHONE#1 Exr• APN# LAND USE APPLICATION# <br /> ( 916) 865-8616 <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR PAUL SINGH CHECK If BILLING ADDRESS <br /> BUSINESS NAME WATERLOO FOOD&FUEL PH NE ExT• <br /> 1 865-8616 <br /> HOME or MAILING ADDRESS 3032 WATERLOO RD FAx# <br /> (209 ) 214-6508 <br /> CITY STOCKTON ` STATE CA ZIP <br /> 95205 <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 Ns application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes Stand ,S1TATE�a/ ]FIEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,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: 'l t s"T 4-;ET'" F 17- <br /> PAYMENT <br /> COMMENTS: <br /> JUL 31 2012 �I <br /> SAN JOAQUIN COUNTY <br /> MENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: OL C j E I",� EMPLOYEE#: DATE: 13t <br /> /12— <br /> ASSIGNED TO: UJ o "'J6— 1 EMPLOYEE#: DATE: -7 3 Z� <br /> Date Service Completed (if already completed): SERVICE CODE: Il7 PIE: <br /> Fee Amount: % .3-7 `� Amount Paid 5 3'7S�- C U I <br /> Payment Date -7 ,3I <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> J <br />