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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID # SERVICE REQUEST # <br /> Type of Business or Property � Zoo <br /> 0 9 <br /> Cardlock � �oo ��,\ 'J <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS ❑ <br /> Carlos Coria <br /> FACILITY NAME <br /> Van De Pol 95366 <br /> SITE ADDRESS E . Front =Rd . Ripon citzI Code <br /> 816 Street Number NON,Direction treet Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) Street Name <br /> PO BOX 1107 Street Number <br /> STATE ZIP <br /> CITY CA, 95201 <br /> Stockton LAND USE APPLICATION # <br /> Exr. APN # <br /> PHONE #1 <br /> ( 209 ) 242-5248 — LOCATION CODE <br /> Ext. [!t <br /> TRICT <br /> PHONE #2 <br /> CONTRACTOR / SERVICE REQUESTOR ON <br /> [2825 <br /> QUESTOR CHECK If BILLING ADORES <br /> onlee Pum Company PHONE # E%T . <br /> SINESS NAME 209 537-9396 <br /> FAx # <br /> ME or MAILING ADDRESS ( 209 ) 537-9398 <br /> Railroad Ave .NONNON STATEZIP <br /> N Ceres , CA. 95307 <br /> BILLING ACKNOWLEDGEMENT:DGdEM/orP T: 1 specificundersigned <br /> property <br /> ty bDEPARTMENusiness 1T hourly pcharges assoerator or ciated project ent of � or <br /> acknowledge that <br /> activity will be billed to me or my business as identified on this form . <br /> I also certify that I have <br /> Codes, this <br /> , STATE and FEDERAL the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY ordinance �7 J G� <br /> DATE : � nC - I / <br /> APPLICANT' S SIGNATURE : qAXk <br /> PROPERTY i BUSINESS OWNER ❑ OPERATOR / MA A ER ❑ OTHER AUTHORIZED AGENT {a Admin . Tale <br /> If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE eNe OR M of any andhall resen pllts , gleotechnical data ande , 1 , the owner or porretor of the <br /> al/i e�assessiimentlocated tinfo taa n <br /> site address , hereby authorize th <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT aS SOOn as It IS available an he same tIn1C It IS provided t0 e Or <br /> my representative . M /fit I LUI <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS: <br /> ENVIRUNMENTA��HEALTH <br /> nFPARTM <br /> n ' n^ EMPLOYEE #: a, r DATE: <br /> ACCEPTED BY: l it/ , � <br /> DATE: <br /> ASSIGNED TO : <br /> �u Ct/')�...� EMPLOYEE #:: �/�� <br /> SERVICE CODE L PIE : <br /> Date Service Completed (if already completed) : <br /> Fee Amount: <br /> Amount Pai L�s6 Payment Date 3 / <br /> Check # 7aZg Re I! ed By : <br /> Payment Type Invoice # 3 <br /> SR FORM (Golden Rod) <br /> EHD 48-02-025 <br /> 07/17/08 <br />