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SAN JOAQ0owCOUNTY ENVIRONNIENTALHEALTH1sf.PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S��G iZ <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Mr Jim C,'Iqrp <br /> FACILITY NAME <br /> Clare Property <br /> SITE ADDRESS 8372 S Jack Tone Road Stockton 95215 <br /> Street Number Direct onStreet Name Ci ZI COCe <br /> HOME or MAILING ADDRESS (if Different from Site Address) P.O. Box 31330 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Stockton CA 95213 <br /> PHONE#1 Err. APN# �_(i��—(X� LAND USE APPLICATION <br /> ( I 06444e-05-- PA-04-519 11 <br /> PHONE#2 E.. BOS DISTRICT 1 LOCATION CODE <br /> ( ) G qcT <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK N BILLING ADDRESS El <br /> Dave Wplrh <br /> BUSINESS NAME PHONE# En. <br /> HOME or MAILING ADDRESS FAX# <br /> 2 Industrial Way (209)369-4228 <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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. PAYIViiENT <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SANJBFQF.IVED <br /> COUNTY Ordinance Codes,Stan r STATE and FEDERAL laws. <br /> n _ <br /> APPLICANT'S SIGNATU � DATE; � –z�)1–� MAR 2 9 2005 <br /> SAN JOAQUIN COUNTY <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Consultant ❑NVUQiyEMAL <br /> /(APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title HEALTH DEPARTMENT <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 /> infOmlation 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 Siitabfffty-StiSr/ Nitrate Loading Study Review <br /> COMMENTS: Please review the following Soil Suitability Study/Nitrate Loading Study. a have attached <br /> the service review fee of$465. If you have any questions please call. <br /> Dave $ it4vra«r <br /> o ay'd <br /> APPROVED BY: EMPLOYEE#: q/.. DATE: <br /> ASSIGNED TO: TrM [,1/rlYJ l // DATE: <br /> SERVICE <br /> Date Service Completed (if already completed): SERCE CODEE:'�7 5� G,- P/E: Z106 Z <br /> Fee Amount: qb.0 Amount Paid i9V4 s Payment Date <br /> Payment Type ✓ Invoice# Check# I G� Received By: zle—_ <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />