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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 Dennis Borba <br /> CHECK if BILLING ADDRESS 0 <br /> FACILmNAME Borba Property <br /> SITE ADDRESS 24011 E. Dodds Rd. Escalon G <br /> 1'S �C <br /> Street Number Direction Street Name Ci C - <br /> HOME Or MAILING ADDRESS (If Different from Site Address) P.O. Box 192 <br /> Street Number Street Name <br /> CITY Escalon STATE CA zip 95320 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 531-3494 207-150-06 1 j D Do'-rD C(M S <br /> PHONE#2 EzT. BOS DISTRICT LOCATION CODE <br /> ( ) oq- <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 /> ( ) <br /> CITY Lodi STATE CA zIP 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 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: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT 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 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 <br /> COMMENTS: <br /> 4 2014 <br /> �Gr✓ j��'^^j ,�V,1 `� SMEJOAQUIN NCOUNr <br /> JWL <br /> r>v <br /> ACCEPTED BY: A EMPLOYEE#: DATE: <br /> ASSIGNED TO: '/ ` EMPLOYEE#: DATE: <br /> Date Service Completed (if already pleted): SERVICE CODE: e�2_ -2 P l E. -7 <br /> Fee Amount:. '- Amount PaidPayment Date �I a <br /> Payment Type Invoice# Check# I Re ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />