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SAN JOAQUIN COUNTY ENwRoNMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5Q©� 3►I <br /> OWNER/OPERATOR <br /> Komal Atwal CHECK if BILLING ADDRESS <br /> FACILITY NAME Baba Atwal Farms <br /> SITE ADDRESS 28488 S. Bird Rd. Tracy 95304 <br /> re <br /> Stet Number Direction Street Name I Zip C.de <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 3701 W. Linne Rd. <br /> Street Number Street Name <br /> CITY Tracy STATE CA ZIP 95304 <br /> PHONE#1T APN# LAND USE APPLICATION# <br /> (209) 298-0313 239-200-13 p ti <br /> PHONE#2 F-xT BO DISTRICT -5LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS El <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE CA Z'P 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 a ion and the the rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar , STATE d FEDa laws <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OwNER1A OPE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> !f APPL/CANT is not the BILLING PAR7Y 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/sPAAmssessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at th� t <br /> provided to me or my representative. Q�' �••' <br /> TYPE OF SERVICE REQUESTED: Review Nitrate Loading Study JUN <br /> COMMENTS: .1 <br /> i HFACNTy4UI)PI )e getipezr -tQ ViR�pMNCO ER <br /> TY <br /> Vz-7//t i9,1 �Z fYlih <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Co pleted if already completed): SERVICE CODE: P I E: <br /> Fee Amount: a Amount Pai •a D Payment ate �I <br /> Payment Type Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />