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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 /> Danny Olmstead CHECK if BILLING ADDRESS <br /> FACILITY NAME WDO Property <br /> SITE ADDRESS 27945 S. Chrisman Rd. Tracy 95304 <br /> Street Number I Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 7701 Bates Rd. <br /> Street Number Street Name <br /> CITY Tracy STATE CA ZIP 95304 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 415) 308-4585 248-080-04 PA-1800125 <br /> PHONE#j EXT. BOS DISTRICT LOCATION CODE <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. ( ) <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 HEAi,rii DEPARTNIFINT 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,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATUR / DATE: <br /> PROPERTY/BUSINESS OWNER OP ATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the propert �ated at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or env ironmenta itt -lit <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL IIEALTH DEPARTMENT as soon as it is available and at Ase,�/ <br /> provided to me or my representative. 4y <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study 9 <br /> COMMENTS: H FI�gQ(/7Co viaN <br /> MF,yT <br /> ACCEPTED BY: ' EMPLOYEE#: DATE: <br /> ASSIGNED TO: V, fvs { EMPLOYEE#: DATE: V� `C'l^_ I <br /> Date Service Completed (if already Completed): SERVICE CODE: Cj P I E:� <br /> Fee Amount: O I T-Amount Pai 3 U Payment Date o! <br /> Payment Type Invoice# Check# g� Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />