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y4 <br /> SAN.TOAQU OUNTY ENVIRO-fMENTAL HEALTH WARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# AR©E REQUEST�� <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Mr- Joe Kowalski <br /> FACILITY NAME <br /> JJGS Corporation Property <br /> SITE ADDRESS 14300 S Campbell Road Escalon 95320 <br /> Street Number Direction Street Name Ci zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 1643 3rd Street <br /> E Street Number Street Name <br /> CITY STATE ZIP <br /> Escalon CA 95320 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> l ) 207-300-17 PA-03-263 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> i ) Ll <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> Dave WpIrh <br /> 4 BUSINESS NAME <br /> PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209)369-4228 <br /> CITY Lodo STATE CA ZIP 95240 <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,Stats s, TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATU DATE: `J —C;,�—( <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT®� Consultant <br /> IfAPPLIC.INT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> E <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 JOAQUtN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the Saltie time it is <br /> provided to me or my representative. ��]T <br /> TYPE OF SERVICE REQUESTED: Expedited Soil Suitability Study/Nitrate Loading Study Review EC�� <br /> COMMENTS: r / '��� <br /> X-, S. 5t ��n��� J� `° s . ,rte - �A 2 <br /> U1N CCu <br /> SAtA���pt4PAR� LNC <br /> E APPROVED BY r EMPLOYEE#: .� DATE: F` <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> .* <br /> Date Service Completed.(if already completed): SERVICE CODE: S 0 <br /> 'Fee Amount Amount Paid I '�. Payment Date <br /> , t : ✓ l:J . �b <br /> Payment Type Invoice# Check# �.� 1 Received By l���,"' <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> 4 <br />