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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> i9e le/(--k <br /> OWNER/OPERATOR <br /> Ram K. Shastri CHECK if BILLING ADDRESS <br /> FACILITY NAME Proposed Prayer Hall (Maha Shakti Ashram Sanstha) <br /> SITE ADDRESS 3885 E. Eiaht Mile Rd. <br /> Street Number Direction Street Name Lodi CIty <br /> —795240e <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> (209 ) 423-4614 Andv Mishra 059-140-23 PA-1300121 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# F <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 forth. <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 /> e <br /> APPLICANT'S SIGNATUREi-4l N �C r/,dam '"— Ev-� ~ Dom'— <br /> PROPERTY/BUSIlVFSS OWNER❑ ---��� OPERATOR/MANAGER ❑ OTAER ALrrHORIZED AGENT❑ <br /> IfAPPLlcANT 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 availablAYMEFfir at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading StudV t1tCE'VE® <br /> COMMENTS: %Af �, ,`, �I I"yt ' JUL 2 5 2014 <br /> 11 <br /> 6 <br /> 3pd nn w ? SAN JOAQUIN N <br /> TM// HEALTH DVpNAAN <br /> �5U/I7lN N'1 s <br /> ACCEPTED BY: EMPLOYEE#: DATE: Z l I <br /> � <br /> ASSIGNED TO: ` z> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: '2 p_ <br /> Fee Amount: —t" Amount Pai Payment Date 7 <br /> Payment Type Invoice# Check# g Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />