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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Javier Gomez CHECK if BILLING ADDRESS <br /> FACILITY NAME Gomez Property, proposed new home <br /> SITE ADDRESS 826W. Bowman Rd. French Camp 95231 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) P.O. Box 1404 <br /> Street Number Street Name <br /> CITY French Camp STATE CA ZIP 95231 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (209) 479-6781 193-260-16 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> 00,-'ZD <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> Live Oak Geo Environmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE CA zIP95240 <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 thatjaws., <br /> ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar TAT d FEDER `�APPLICANT'S SIGNATU�RyE/: DATE: I— `5 <br /> PROPERTY/BUSINESS OWNERIrJ O ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is n t the LLLING PARTY proof of authorization t0 sign is required Title <br /> AUTHORIZATION TO REL ASI 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. <br /> TYPE OF SERVICE REQUESTED: Review Nitrate Loading Study RECEIVED <br /> COMMENTS: /�1,LbT-0 Miat/!•¢�1 eew <br /> Z�a,�so,g /IP,,r'eN/ s�� � JAN 25 2090 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: p'1a✓�u/a11rn EMPLOYEE#: DATE: `-�-5_ 1 r <br /> ASSIGNED TO: �,. EMPLOYEE#: DATE: t-} rb <br /> Date Service Completed (if already completed): SERVICE CODE: S Z� PIE: 2-604 <br /> Fee Amount: 30LA w Amount Paid 3 — Payment Date <br /> Payment Type Invoice# Check# 0 01 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />