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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -7o s-1 <br /> OWNER/OPERATOR 6(Zt-Cs F>L)r-pi S <br /> CHECK if BILLING ADDRESS X <br /> FACILfTY NAME 3E C OTi-b LV-C)P E Iz-T\t <br /> CIT.Annncnn �(}�p N �Pc\/I S I-D <br /> Sheet Number Di cin Street Name city zipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) O avX I'+0(p <br /> Street Number Street Name <br /> CITY w O ODB�t D�t STATE C IN ZIP <br /> `15 z-s� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Ocl ) 013 - oso - +3 <br /> PHONE#2 EXT. BOS DISTRICT LOCA ON 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 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 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: z6glt4 DATE: t o - <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT® CONSV L 1 Py1 T- <br /> I f APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tule <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 environmentaUsite 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: �ZC VI t W S U(L t A C E + S,)gS u f-f'Ac r`, C O^,TPVM i 1Q o t O-f'J tQ t�P ff� <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVE® <br /> OCT-2 8 2014 <br /> ACCEPTED BY: ^�U�� EMPLOYEE#: ENVII€ENTAI►o Z (-E- <br /> ASSIGNED TO: �!l7 EMPLOYEE#: ATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3( 5 P/E: 2 J <br /> Fee Amount: 1 (� Amount Paid Payment Date I b �Y <br /> Payment Type Invoice# Check Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />