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SAN JOAQUI*OUNTY ENVIRONMENTAL HEALT *EPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if BILLING ADDRESS❑ SERVICE REQUEST # 12- � �o 7 373-1166 EXT. S'w ov (/ ls"s` OWNER / OPERATOR FAX # (916) Teichert Construction CHECK if BILLING ADDRESS❑ FACILITY NAME ZIP 95691 Teichert Mobile Equipment SITE ADDRESS 120 Frank Circle ACCEPTED BY: Stockton -T 95206 Street Number Direetlo� wOST" Street Name ASSIGNED TO: CI Zip Code HOME or MAILING ADDRESS (if Different from Site Address) PO BOX 15002 Street Number Street Name CITY Sacramento STATE CA Zip 95851 PHONE #1 ExT• APN # LAND USE APPLICATION # (916) 366-8631 Payment Type PHONE #Z ExT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Dul c inea Covan CHECK if BILLING ADDRESS❑ BUSINESS NAME Walton Engineering, Inc. P§TV 373-1166 EXT. HOME or MAILING ADDRESS P.O. Box 1025 FAX # (916) 373-1173 CITY West Sacramento STATE CA ZIP 95691 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 FEDERAL laws. APPLICANT'S SIGNATURE: '� DATE: �" 1�'I o PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT U Compliance Manager If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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. V.4 U ✓1'1 r-�� TYPE OF SERVICE REQUESTED: S D COMMENTS: SAN 3 0 1010 ENVIRUNMENT HEALTH PERMIT/SERVICES ACCEPTED BY: EMPLOYEE #: 032-1 DATE: / 3 ! C C ASSIGNED TO: (j�j ��(�i EMPLOYEE #: �3I —7 DATE: 3o C -G Date Service Completed (if already completed): SERVICE CODE: pit: Fee Amount: x66 Amount Paid % 3 b Payment Date 3C) Payment Type Invoice # Check # q3 --)-7z) 1 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003