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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 9�C ob 774o"�9 <br /> OWNER/OPERATOR <br /> Joseph Sanguinetti CHECK if BILLING ADDRESS� <br /> FACILITY NAME Sanguinetti Property <br /> SITE ADDRESS 18626 E. Copperopolis Rd. Linden 95239 <br /> Street Number I Direction I Street Name city ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> same <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex . APN# LAND USE APPLICATION# <br /> (209) 482-0638 183-210-01 & -02 PA-17-75 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) \ 1`) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> euslNEss NAME PHONE# <br /> Live Oak GeoEnvironmental Ez . <br /> 209 369-0375 <br /> HOME or MAILING ADDRESS Fax# <br /> 407 W. Oak St. <br /> (209)369-0377 <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 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 SIGNATURE: DATE: (2 - 1 2 <br /> IN - IL� <br /> PROPERTY/BUSESS OWNER❑ OPERATOR/ OTHER AUTHORIZED AGENTM LtrTnFv 14--✓—+— <br /> IfAPPZICANT is not the BILLING PAR TP proof of authorization to sign is required Titre <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 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 Soil Suitability Study Ja.i <br /> Al <br /> COMMENTS: <br /> fZc-J�lL7 YIt3/It�JL-7� 6 fl v"� y�<TH���Y�eN <br /> �l- <br /> �90 n,;i cS� Np <br /> ACCEPTED BY: EMPLOYEE#: DATE: / . ��- J­7 <br /> ASSIGNED TO: EMPLOYEE#: DATE: /W ./� ,I-7 <br /> Date Service Completed (if already completed): SERVICE CODE: lJ� P 1 E: -�2(v d <br /> Fee Amount: �?-"?13 co Amount Paid .27X 0 D Payment Date 4p j 2 <br /> Payment Type Invoice# Check# sO� Recei ed y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />