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! SAN JOAQUI.�:'OUNTY ENVIRONME 4 I AI HEALTH, _ , ARTMENT <br /> SERVICE RE1UEST <br /> Type of Business or Property FACILTN ID# SERA g REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Mr. Michael HoIMP.-, <br /> FACILITY NAME <br /> Holmes Pro ert <br /> SITE ADDRESS m S Biederman Way Escalon 95320 <br /> Street Number Direction tree[ a cityZi Code <br /> HOME or MAILING ADDRESS llf Different from Site Address) P.O. Box 31731 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Stockton CA 95213 <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> l ) <br /> 1205-190-11 PA-04-454 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION Co <br /> t ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> Dave WpInh <br /> BUSINESS NAME PHONE# ExT• <br /> Neil 0- Andprson and ASqarm;itt-,;- Inc- 1209)367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way (2 )369-422 <br /> CITY Lado STATE CA ZIP 95940 <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> t 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 F,EDERALL laws. JJ�� <br /> APPLICANT'S SIGNATURE: <br /> DATE: �CJ <br /> PROPERTY/BUSINESS OWNER 13 OPE I MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY.proof of authorization t0 sign is requited Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner 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: Soil Suitability Study Review <br /> COMMENTS: y`i i t=l <br /> Please review the following Soil Suitability Study. Mr. Michael Holmen t$apl'l�the <br /> service review fee of$186. If you have any q estions please call. <br /> Dave t513�l0� tv�r � APR 1 °J 2005 <br /> SAN JO LAN COUNTY <br /> l APPROVED BY: U( EMPLOYEE#:D 3 HEALTH @F'RtiTMI� f g�b5 <br /> ASSIGNED TO: ' G O'- -EMPLOYEE#: -S-ti r-(L DATE: <br /> Date Service Completed (if already carnpleted): SERVICE CGDE: PIE: �(, p <br /> y 'Fee Amount: Amount Paid Payment Date. D <br /> Payment Type Invoice# Check# Re elve Sy: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />