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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S P\oo +rl-5 zt <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS 10 <br /> Mr Jim Bird <br /> FACILITY NAME <br /> Bird Electric <br /> SITE ADDRESS ."l J5 ��-W Stockton 9521,rj <br /> Street Number Direction m Zi CoEe <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> (0`6� I �•W, <br /> / Stre�Number l Str N <br /> CITY C 1 _ STATE C � ZIP <br /> [IHONE#1 J�-ZJ E T. APN# LAND USE APPLICATION# j <br /> 179-082-02 PA-05-708 (SA) <br /> NE#2 Exr. BOS DISTRICT LOCATION CODE <br /> I c - 9 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR <br /> CHECK if BILLING ADDRESS <br /> Nancy Rrimilek <br /> BUSINESS NAME PHONE# Ex. <br /> NP41 C) Anderson and Associatpq Inr. ( 20A)'467-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 industrial Way (2091369-4228 <br /> CITY I nfie <br /> STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <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 /> 1 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. /p <br /> APPLICANT'S SIGNATURE: iys�y 2 .tIL.�I DATE: �/// / 06 <br /> I <br /> PROPERTY/BUSINESS OWNER IL'✓( OPERATOR/MANAGER 13 OTHERAUTumuz DAGENTO <br /> IfAPP/aCANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 RECEIVED <br /> COMMENTS'- -L f <br /> Ll� o,s,,1 1 11 U��u,r to1Z�IDv R1�1'u" c JUL - 7 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> 1117 <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: -�I_n 1"l QM1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed)(:/ G 1`- SERVICE CODE: 57 PIE: -2(,d 2 <br /> Fee Amount: Amount Paid Payment Date fl <br /> Payment Type ✓ Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />