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SAN JOAQUIN COUNTY ENvIRONNLENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST _ <br />Type of Business or Property <br />Commercial Office Building <br />FACILITY ID # SERVICE REQUEST # <br />SOocciog- <br />OWNER / OPERATOR <br />Pacific Gas and Electric CHECK if BILLING ADDRESS <br />FACILITY NAME <br />McDonald Island Accessory Building <br />SITE ADDRESS <br />2121 Street Number Direction <br />Zuckerman Rd. <br />Street Name <br />Stockton <br />City <br />95206 <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />6121 <br />Street Number . <br />Bollinger Canyon Rd. <br />Street Name <br />Zip Code <br />CITY San Ramon STATE CA ZIP 94583 <br />PHONE #1 <br />( ) <br />EXT. APN # <br />129-080-090 <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. BOS DISTRICT 11 LOCATION Cc4E, <br />NTRACTOR / <br />REQUESTOR <br />Paige Noga CHECK if BILLING ADDRESS <br />BUSINESS NAME Blair, Church, & Flynn PHONE # EXT. <br />(559)326-1400 <br />HOME or MAILING ADDRESS <br />451 Clovis Ave. FAX# <br />( ) CITY Clovis, CA STATE CA ZIP 93612 <br /> . i, me undersignedproperty 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 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 CouNTv Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: Paige Noga <br />Project Engineer <br />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 provided to me or my representative. <br />I <br />TYPE OF SERVICE REQUESTED: Review of soil suitability and nitrate loading testa. <br />COMMENTS: R tf c evc../ tr;c, e vviei i'l cold •clwa rckei -6 e-4 yezi j ns-p rc;-ic.7r: <br />- <br />ii'CILI. <br />1 V <br />MAY 1 <br />3 20, SAN j0 <br />I- i 6 A1-„_,V IR81\78.A.,_Al COU , <br />DATE:4.- ACCEPTED BY: EMPLOYEE #: --'/, .4" <br />ASSIGNED TO: ."1 y9 EMPLOYEE #: <br />'"k7 <br />DATE: <br />Date Service Completed (if already completed): SERVICE CODE: s- „? 3 P / E: 42, 60 42 <br />Fee Amount: :II: OF Amount Pail? 6 og: (57) Payment Date 57/3/21 <br />Received By: 7,0— Payment Type diedd- Invoice # 3 5.-- 2_,,si...; Check # 1 25 2233 ,..F4 <br />DATE: 5.12.21 <br />PROPERTY / BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BIIIING PARTY, proof of authorization to sign is required <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod)