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SAN JOAQUN-C OUNTY ENVIRONMENTAL HEALTH beePARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Spalpffa Reynolds Partnership, C/O Mr Torn Padayh2q <br /> FACILITY NAME <br /> S aletta-Re nolds Property <br /> SITE ADDRESS 2677 Zuckerman Road, McDonald Island Stockton <br /> Street Number I DirecHon Street Name city MP Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) P.O. Box 844 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Stockton CA 95201 <br /> PHONE#1 Ev. APN# LAND USE APPLICATION# <br /> ( ) 129-080-07 57 61 & 63 Unassigned <br /> PHONE#2 BOS DISTRICT LOCATION COOS <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En. <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITY LodSTATE 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. <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. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT 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 t0 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 SERVICEREQUESTED: Soil Suitability Study Review <br /> COMMENTS: Please review the following Soil Suitability Study. The client will attach the service review <br /> fee of$186. If you have any questions please call. <br /> Dave 6/ice/oS. <br /> 2Fr'Ji7Es Ji�� <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />