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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ) -0 O <br /> OWNER/OPERATOR Carl Navarra CHECK if BILLING ADDRESS <br /> FACILITY NAME Navarra Property <br /> SITE ADDRESS 25000S. Bird Rd. Tracy <br /> Street Number Direction I Street Name City Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 475 Blewett Rd. <br /> Street Number Street Name <br /> Cm Tracy STATE CA zip <br /> 95304 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 836-0005 1239-110-05, portion of -04 ! - 11 wo j <br /> PHONE#2 ExT. BOS D TRICTLOCATM CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. (209)369-0377 <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAV..and FEDE L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOd MANAGER ❑ OTHER AUTHORIZED AGENT G O-JSyLTA/V T <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tirte <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 <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study RECEI <br /> COMMENTS:; MAY 0 4 2015 <br /> `7' SAN JOAQUIN COUIy ry <br /> HEALTH D ARTME <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: S <br /> ASSIGNED TO: lGy�u �L{V y EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 Z PIE: 2L c <br /> Fee Amount: ZL i7 Amount Paid ,26o . Payment Date S/q//S <br /> Payment Type Invoice# Check# 4 9 Z_ Received By: (6 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />