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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />COMMENTS: <br />PHONE # ExT• <br />916-373-1165 <br />_ <br />FAX # <br />( ) <br />CITY wrest Sacramento <br />STATE CA ZIP 95691 <br />OWNER /OPERATOR <br />Colonial <br />Energy, LLC, <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Colonial Energy40134 <br />SITE ADDRESS <br />At <br />ACCEPTED BY: , <br />EMPLOYEE #:NN 11.64%,— a� MEN I <br />—7 <br />1434 <br />`` <br />W* Yosemite <br />Mantec <br />9573 <br />Street Number <br />Di� tion <br />Street Name <br />�9 <br />i <br />ZI" <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />L7^� <br />Street Number <br />Street Name°�Se �e <br />CITY <br />STATE zip 414 p <br />(g / <br />PHONE #1 Err. <br />APN # <br />LAND USE APPLICATION # ' AI,I JOA <br />l ) <br />2 <br />cl k3 2 <br />EIyVjR� Cl/ty <br />2-2--2 ..7 <br />H C <br />PHONE #2 ExT. <br />BOS DISTRICT <br />LOCATION pxl <br />OL i <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Walton Enngineering, Inc. <br />CHECK if BILLING ADDRESS® <br />BUSINESS NAME <br />Walton Engineering, Inc. <br />COMMENTS: <br />PHONE # ExT• <br />916-373-1165 <br />HOME or MAILING ADDRESS <br />P.O. Box 1025 <br />FAX # <br />( ) <br />CITY wrest Sacramento <br />STATE CA ZIP 95691 <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 ENVIRONMEN'rAL 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, SrATF an FF ERAL laws. <br />APPLICANT'S SIGNATURE:DATE: <br />PROPERUY / BusINF.ss OWNER❑ OPERA OR / MANAGER ❑ OTHER AUTHORIZED AGENT <br />IfAPPLICAN'T 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 HFALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my represcnlAve. r <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />At <br />ACCEPTED BY: , <br />EMPLOYEE #:NN 11.64%,— a� MEN I <br />ASSIGNED TO: /! ►/1 <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: t ( <br />PIE:7� <br />Fee Amount:/ <br />Amount Pai <br />�9 <br />Payment Date <br />f g <br />Payment TypeInvoice # <br />Ch k # g3 z9r <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />elvr <br />V�e® <br />?0l8 <br />UNTy <br />14 <br />ENT <br />