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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # CBCs S'�cx\\C:(-"\ ACCEPTED BY: CHECK if BILLING Atmness OWNER I OPERATOR DA7E: PHONE# ExT. Walton Engineering, Inc CHECK it BILLING ADDRESS ❑ Flyefs Energyt LLC 3734166 HOME or MAILING ADDRESS FACILiTi' NAME FAX # Pa ment Date fs Flyers 9427 Involce # f ? SITEADDRESS 33M CITY West Sacramento Waterloo Road sto0torl 95265 Street Number Direction Street Name City ZID code HOME or MAILING ADDRESS (If Different from Site Address) 2380 Mdbergh Street Street Number Street Name CITY STATE ziP Aubum CA 95662 PHOItE #1 EXT. APN # LAND USE APPLICATION # f ) Pttolm 42 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR f SERVICE REQUESTOR REQUESTon x❑ VerontcaFreltas ACCEPTED BY: CHECK if BILLING Atmness BUSINESS NAME DA7E: PHONE# ExT. Walton Engineering, Inc DATE: 948 3734166 HOME or MAILING ADDRESS Fee Amount" � . - .0 r(j(�j Amount Pal FAX # Pa ment Date fs P.O. Box 9025 Involce # f ? Check # �$ S CITY West Sacramento STATE CA ZIP 95691 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknoi*dge that all site andior project specific ENVIRONMENTAL HEAt.TH DEPARTMENT hourly charges associated with this project or `. activity will be billed to me or my business as Identilled on this form. 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 Cortes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: &Zi,�_ (.� DATE:7 t-( 1•-') PROPERTY I BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ OTHER AUTHORIzea AGENT ®, Contractor If APPtrcANr is not the BPLLING PAFRTY, 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 andior environmentaltsite assessment Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avallable and at the sante time it Is provided to me or my representative. TYPE Of: SERVICE REQUESTED: t -,f ST COMMENTS: a a � 2 ACCEPTED BY: EMPLOYEE #: DA7E: AssIGNED TO:t �t l r EMPLOYEE #: DATE: Date SerVICO Completed (if already oompleted):� a SERViCECODE: PIE: Fee Amount" � . - .0 r(j(�j Amount Pal /a, Pa ment Date fs Payment Type t/1 k Involce # Check # �$ S Recelve By: EHa 48.02.025 SR FORM (Golden Rod) 07117108