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SAN JOAQUIN COUNTY ENVIRONMENTAL NEA1t.AM DEPARTMENT <br /> SERVICE REQUEST `• <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR JOHN WATHEN, SHIMMICK CONSTRUCTION CHECK if BILLING ADDRESS <br /> 1 <br /> FACILITY NAME BIRD ROAD FACILITY <br /> f <br /> SITE ADDRESS 23751 SB ROAD TRACY <br /> Street Number DirectionStreet Namecity Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 24200 CLAW ITER ROAD <br /> i <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> :. HAYWARD CA 94545 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( } 250-100-03 0 1 <br /> PHONE#2 EXT. 60S DISTRICTLOCAT10 CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR NANCY KRAMER <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ems' I <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902-Industrial Way (209 )369-4228 <br /> Clrt Lodi STATE CA ZIP 95240 I <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 i <br /> or activity will be billed to me or my business as identified on this form. <br /> f <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 /> I COUNTY Ordinance Codes,Standards,STA E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: )� t,sw DATE: /-V2 blo 17 <br /> I' <br /> PROPERTY/BuSINFSS OWNER 13 J OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT 1Wc— <br /> r1'1A�'1N i <br /> 1 <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 <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/NITRATE LOADING STUDY PP. VEp j <br /> /Comm NT: �1.�MA SAN 2ooa I <br /> sAt4 JOAc�u»CoVAL <br /> Ut4TY <br /> HEA�Ti i DEPARTMEW <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> I <br /> ASSIGNED TO: EMPLOYEE#: U DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> I <br /> Fee Amount: 1/' Amount Paid Payment Date ( D <br /> Payment Type Invoice# Check# Received By: i <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />