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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or ProArth Bare L FACILITY ID# SERVI EST# N/A OWNER 10 See Ment One FACILITY MCHECK if 81LLING A ESN�A SITE ADDRESS 8 g 5 3 Street N1 imber5 Manthey Road iractl tree! a e �French Camp 9P,211 HOME or MAILING ADDRESSAddress)If Different from Site Addc U -J, y 6.7,35 #B ` Street Number N• /Herndon Avenue CITY Str et a e Stockton y' k' ?CA TATE'+ zip PHONE#1 Exr. " ' 95207.. (2 0 9) 951-9900 APN# f f `LAND USE APPLICATION,# 193-20006 PHONE#2 r_ } l.' PA 06.00651 Exr. - ( BO$DISTRICT 1 Y c LOCA I N E f � r REQUESTOR CONTRACTOR/SERVICE REQUESTOR ' David Silva n /,: ,.CHECK If BiLLINGAAIDRIS, BUSINESS NAME i � � 1� •_ Nonef, y f r `f� Y� �y PHfflJ Exr.982-1 114 HOME or MAILING ADDRESS •� � t J FAX# CITY 6624 Chesa Bake. C'-Ircle ,' ,` x '(209) 982-5834 Stockton \11� � �F ./' - STATE CA ZIP 95219 BILLING ACKNOWI,EDGEMI 1VT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associat or activity will be billed to me or my business as identified on this form. ed with this project I also certify that I have prepared this application and at the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,S and RAL I s. APPLICANT'S SIGNATURE: A DATE: �-02 d O 7 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT a BLl er of Property IfAPPL1CANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: tJ�� COMMENTS: Review and Approval on an 'expedited basis of the -NeilAnderson Soil Suitability Stuy and Nitrate Loading E til i PA-0600651 for APN 193-200-06 APW- -�7r�.0MryIJ /tJihLc�e L®eGLwy ,P�,�,- dv d/�l f C' u iy�`f I ACCEPTED BY: a } EMPLOYEE#: � DATE, t3 I � ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: i Fee Amount: y, S Amount Paid s c) Payment Date !! Payment Type f' Invoice# Check# 3 b �{L{,�3 S Received By: EHD 48-02-025 I REVISED 11117/2003 SR FORM(Golden Rod)