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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUES' % <br /> Type of Business or Property FACILITY IDI SERVICE REQUEST#' <br /> �rSQ/ 3 z <br /> OWNER I OPERATOR Garello Design LLC <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> .fl <br /> SITE ADDRESS 4065-4080 E Calloway Court Stockton <br /> Street Number I Direction Strajot Name Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> L r <br /> (� <br /> F.C/J),. `.J� IqW�.. � Street Number Street Name {� <br /> CITY �e r� ''/L �- � PAr (�^ �' Or STATE ZIP 3 q S3 <br /> t 1 r I �Ji <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> 087-220-02103 PA-06-313 (SA) <br /> PHONE#2 ExT SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR IV _ <br /> �• '_t o CHECK If BILLING ADDRESS <br /> BUSINESS NAME � lam— PHONE# E.T. <br /> • :'��F IC �5 SsoccA ? (a 2i?0 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE Cds ZIP qs-2-4 o , <br /> wBILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> i 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,Sion TA FERE <br /> APPLICANT'S SIGNATU DATE: <br /> PROPERTY/BUSINESS OWNER❑ RATO / THERAUTHORIZED AGENT <br /> � <br /> If APPLICANT is no the BILL RTP proof of authorization to sign is required Title <br /> i AUTHORIZATION TO RELE FORMATION: 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 1 Nitrate Loading Study <br /> 1 <br /> COMMENTS: C„"'.1 L�t.1�T--- <br /> �,C - -6 V�C? �G� C"`S J L'C "OY` <br /> S" <br /> p,i'R <br /> 10 <br /> APPROVED BYL .�. EMPLOYEE ff: DATE: <br /> ASSIGNED TO: EMPLOYEE M. DATE' <br /> Date Service Completed;(if already completed): SERVICE CooE: �z PIE: <br /> Fee Amount :: `7 Amount Paid ? ; Payment Date <br /> t <br /> Payment Type .: Inrioice'# Check# " yl�� Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />