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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> GC`7 S`\C.� �cc F)O OaO� (aOO S1K 008 U1q <br /> OWNER / OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Flyers Energy , LLC <br /> FACILITY NAME <br /> Flyers #427 <br /> SITE ADDRESS 3300 Waterloo Road Stockton 95205 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2360 Lindbergh Street <br /> Street Number Street Name <br /> CITY Auburn STATE ZIP <br /> CA 95602 <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Veronica Freitas CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT' <br /> Walton Engineering , Inc 916 373-1166 <br /> HOME or MAILING ADDRESS FAX # <br /> P . O . Box 1025 ( ) <br /> CITY West Sacramento 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 ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project Or <br /> activity will be billed to me or my business as identified on this form , <br /> 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE : E'0 CDATE . t 1 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Contractor <br /> If APPLICANT 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It IS provided to me or <br /> my representative . p <br /> TYPE OF SERVICE REQUESTED : t4ST (J ' <br /> COMMENTS : <br /> �' /�Q o /Y� S ? O <br /> 0? <br /> yEq c�y�O/ �� co�,y� <br /> Fpg6NUj Ty <br /> ACCEPTED BY : f�(�/ EMPLOYEE # : DATE : /2 i/ <br /> ASSIGNED TO : tJ / an0� /A: <br /> EMPLOYEE # : DATE: �2 5 Z <br /> Date Service Completed (if already completed) : r 3 'ZOza I SERVICE CODE : / q Oe?yr P I E : .;?0De <br /> Fee Amount : �� t 1� r0(� Amount Pai q/a , 60 Payment Date l� <br /> Payment Type Invoice # Check # �g0 Receive By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />