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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUE2ST# <br /> Orchard/Commercial Nursery 5� bUO2� J <br /> OWNER i 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 city 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 /> ( 209 ) 599-2900 226-150-27 and 28 PA-2000069(MS) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION C07E <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <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,Stand , d FEDERAL la s. <br /> APPLICANT'S SIGNATURE: DATE: ') - �3-ZC"2-0 <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER D OTHER AUTHORIZED AGENT O <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/sitepassessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sai4i ' <br /> provided to me or my representative. R t y� N7- <br /> TYPE OF SERVICE REQUESTED: D <br /> COMMENTS: 32 0 <br /> Please review soil suitability studies and nitrate loading studies in conjunction with PA-2000t,'A <br /> �TH p pgRTp Ty <br /> Mtv?- <br /> ACCEPTED <br /> ACCEPTED BY: 7 Z a EMPLOYEE#: DATE: <br /> ASSIGNED TO: J J EMPLOYEE#: DATE: 9 A�apaU <br /> Date Service Completed (If already Completed): SERVICE CODE: 'C' P/E: d6 <br /> Fee Amount: Amount Pai Payment Date 'q�3 2 <br /> Payment Type Chi Invoice# Check# S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />