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SAN JOAQUOOUNTY ENVIRONMENTAL HEALTI &PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Property at 198-120-09 �pb��c�-7 52O6 --27y ) 9 OWNER/OPERATOR HOME or MAILING ADDRESS 837 Shaw Road COMMENTS: Reynolds and Brown CHECK If BILLING ADDRESS FACILITY NAME 17100 Murphy Parkway (work on 17200 Murphy Parkway APN 198-120-05) ZIP 95215 SITE ADDRESS 17200 Murphy Parkway I Lathrop 95330 Street Number Dire tion Street Name R city ZipCode HOME or MAILING ADDRESS (If Different from Site Address) EMPLOYEE #: 1200 Concord Avenue, Suite 200 Reynolds and Brown Street Number Street Name CITY Concord STATE CA ZIP 94520 PHONE #1 EXT. APN # P I E: U Z LAND USE APPLICATION # ( 925 ) 674-8400 Amount Paid (� Payment Date c� l PHONE R ExT• Invoice # BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR VUlliam Little CHECK If BILLING ADDRESS BUSINESS NAME Advanced GeoEnvironmental, INC. PHONE # 209 EXT• 467-1006 HOME or MAILING ADDRESS 837 Shaw Road COMMENTS: FAX # CITY Stockton STATE CA ZIP 95215 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: �51� (tet Zti �i� DATE: PROPERTY / BUSINESS OWNER 13OPERATOR/ MANAGER 13OTHER AUTHORIZED AGENT f L7eOlOg IS 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. TYPE OF SERVICE REQUESTED:Lv�— pAY,yf L COMMENTS: AM /VAD y� coo 06 R ACCEPTED BY: EMPLOYEE #: DATE: ^ ASSIGNED TO: ;�"� Q gl /ncl,/i % EMPLOYEE #: DATE: _ Date Service Completed (if already completed): SERVICE CODE: �3 P I E: U Z Fee Amount: Amount Paid (� Payment Date c� l Payment Type Invoice # Check # 2 2 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003