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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS❑ FACILITY ID # SERVICE REQUEST # I- r FAx # v3`j � G�-c7 ��-c-�,�utc�� Z-o✓-i� -- S.t�T� cod uQ OUB S S(0 9 OWNER / OPERATOR a Fp�RTT�� ry ❑ '-t/ L ACCEPTED BY: S. S h l h CHECK if BILLING ADDRESS FACILITY NAME 't DATE: — October 5,9099 ASSIGNED TO: A. Salinas SITE ADDRESS. DATE: Date Service Completed (if already completed): SERVICE CODE: 523 Street Number Direction Street Name yment Date / Z�2- city de NOME Or MAILING ADDRESS (If Different from Site Address) 3 S 3 7 k(� 7 LVr- Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # ZOq —2,50 — Lo LAND USE APPLICATION # 6 PHONE #2 Exr. ( } SOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS❑ BUSINESS NAME (c t 5-4 + 02. L cam -,1.6-1 PHONE # EXT. Z coOSZ HOME or MAILING ADDRESS FAx # v3`j � G�-c7 ��-c-�,�utc�� Z-o✓-i� -- S.t�T� cod ( } CITY ST TE ZIP q Z GG 3L BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will he billed to me or my business as identified on this form. 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 COUNT' Ordinance Codes, Standards, STATE and FED L laws. APPLICANT'S SIGNATURE: DATE: Cy 1YZZ0z1Z PROPERTY / BUSINESS OWNER OPERATOR AGE OTHER AUTHORIZED AGENT -n' CO --5 sU YI If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment 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. p,,(, yn TYPE OF SERVICE REQUESTED: Soil Suitability and Nitrate Loading Study C /y� COMMENTS: rr<yC A T GTi[J Sq�✓O S?O? uNil - LAAJD (ISe 50lL 5V1-rA61U-rT A,-rA4Tt &OVU-� s a Fp�RTT�� ry 5U(7nruT AitXVr- l xAv,0 �D ACCEPTED BY: S. S h l h EMPLOYEE #: DATE: — October 5,9099 ASSIGNED TO: A. Salinas EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: 523 PIE: 2602 Fee Amount: $624 Amount Paid &Z4 1 yment Date / Z�2- Payment Type credit Invoice # Check # k 017 I3' 1 3 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003