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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Orchard/Commercial Nursery SO-- <br /> OWNER/OPERATOR <br /> David Fredriks CHECK If BILLING ADDRESSO <br /> FACILITY NAME <br /> SITE ADDRESS 23223 South Austin Road Ripon 95366 <br /> Street Number I Direction Street Name citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 23245 South Austin Road <br /> Street Number Street Name <br /> CITY Ripon STATE CA ZIP 95366 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> l 209 ) 599-2900 226-150-27 and 28 PA-2000069(MS) <br /> PHONE#T EXT. BOS DISTRICT LOCATION COD <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS El <br /> David Fredriks <br /> BUSINESS NAME PHONE# ExT. <br /> 209 599-2900 <br /> HOME Or MAILING ADDRESS FAX# <br /> 23245 South Austin Road ( ) <br /> CITY Ripon STATE CA ZIP 95366 <br /> BILLING ACKNOWLEDGEMENT: I, 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 /> 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,Sddrds;g`F E an EDE s. <br /> APPLICANT'S SIGNATURil DATE: C "— i <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <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 /> 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: /O <br /> COMMENTS: Il/, <br /> Please review Surface and Subsurface Contamination report in conjunction with PA-2000069(MS). <br /> NFq�T�RO�'/N <br /> ACCEPTED BY: 7 �' EMPLOYEE#: DATE: S �3 Zit✓ qRT �tiTy <br /> ASSIGNED TO: EMPLOYEE#: DATE: I3 ZJZO FNT <br /> Date Service Completed (If already Completed): SERVICE CODE: c P/E: 07 603 <br /> Fee Amount: 3 pL' AmountP ' 36 �� Payment Date l3 <br /> Payment Type Invoice# Check# Sl�'7 Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />