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SAN JOAQUIN COUNTY ENN7RONi1IENTAL IIEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Motorcycle Riding School <br />PHONE# ExT. <br />CF�V�O <br />"s (2 � <br />OWNER / OPERATOR <br />HOME or MAILING ADDRESS 13900 Harlan Road <br />WLE RE, LLC <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Eagle's Nest Harley Davidson Motorcycle School <br />STATE CA ZIP 95330 <br />SITE ADDRESS 1362 <br />North <br />Shaw Road <br />I <br />Stockton <br />95215 <br />Street Numb <br />Mi <br />Street Name <br />DATE: COT -2 <br />City <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 13900 <br />Harlan Road <br />Street Number <br />Street Name <br />CITY Lathrop <br />STATE CA ZIP 95330 <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />(916)929-4680 <br />14326006 <br />PHONE #2 ExT <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Andrew Westbrook <br />CHECK if BILLING ADDRESS❑ <br />BUSINESS NAME Eagle's Nest Harley Davidson <br />COMMENTS: <br />PHONE# ExT. <br />CF�V�O <br />916 929-4680 <br />HOME or MAILING ADDRESS 13900 Harlan Road <br />FAx# <br />CITY Lathrop <br />STATE CA ZIP 95330 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site ainVor proiect specific ENVIRONMENTAL 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, STATE and ww'. I I <br />APPLICANT'S SIGNATURE: <br />PROPERTY/ BUSINESS OWNER® OPERATOR / NIANACER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICAtdT is not the BILLIA-G PART), proof'of authorization to sign is required Tale <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the ovrner 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 HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: S3 1 1 �u ; }a L, �,) qnc <br />r! I �r<, LD<rGi�► <br />? U r ' ; vieLy PI'! <br />COMMENTS: <br />CF�V�O <br />SEP 0? <br />SgNJp <br />AUI <br />FNQ <br />MEAL H p NA.- Nry <br />ACCEPTED BY: L Z <br />EMPLOYEE #: <br />DATE: COT -2 <br />ASSIGNED TO: / / E <br />EMPLOYEE M <br />DATE: / J% <br />Date Service Completed (if already completed): <br />SERVICE CODE: S d 3 <br />P i E: <br />Fee Amount: d <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />9 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />