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5 r I SAN JOAQUII OUNTV ENVIRONMENTAL HEALTH L�: ARTMENT <br /> SERVICE REQUEST <br /> Type`of'8asittess or Property <br /> FACILITY ID# _-,---SERVICE REQ�f1EST <br /> �# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> FAcrLITY NAME <br /> McClellan Pro ert <br /> SITE ADDRESS 24901 S i. <br /> Street Number Direction Bird Road Tracy 95304 <br /> HOME or MAILING ADDRESS (If Different from Site Addressl Street Name <br /> Zi C de <br /> Po Box 685 <br /> Cin. Street Number treat Name <br /> Ennis .STATE Zip <br /> PHONE#1 En. APN# <br /> 2091 833-7304 LAND USE LIGATION# <br /> 250-230-01 & 252-740-OT unassigned a�4� <br /> PHONE#Z Exr. <br /> It $OS DI ICT - LOCATION ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEsroR Nancy Rosulek <br /> CHECK if BILLIN�DRESS <br /> BUSINESS NAME <br /> Neil O. Anderson &Associates ETFAX <br /> ONE# I>R. l <br /> HOME or MAILING ADDRESS - I <br /> 209 369-4228 # <br /> CITY 1 -4. 2 <br /> STATE ZIP 5240 <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 /> 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: // -- i l <br /> �t]ATE: to i <br /> PROPERTY/BUSINESS OWNER❑ ORATOR/MANA ER 13tE AIIT.HORIZED AGENT <br /> 01 <br /> If APPLICANT is not the BimNG 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/siteassessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is h <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Soil Suitability Study ,- <br /> COMMENTS: A,y,s,eJ G .+ RECEIV@ <br /> F4s- <br /> ,� 11 JUN 13 2005 <br /> SAN JoAcaulN COUNTY � <br /> ENVIRONMENTAL � <br /> HEALTH DEPARTME <br /> APPROVED BY: / EMPLOYEE#: DATE: <br /> ASSIGNEE TO: EMPLOYEE#: <br /> Date Service. mpleted (if already completed): SERVICE CODE:. )E; <br /> Fee Amount: Amount Paid �'Ep`oct <br /> OC) <br /> , Paymerit ate lo — <br /> Payment <br /> ��— <br /> � <br /> Payment Type ✓ ;. Invoice# Check#. 5 1[ Received B <br /> + y:`! . <br /> EHD 48-01-025 <br /> REVISED 6-5-02 SERVICE REQUEST FORM <br />