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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 /> Roopa Delapena CHECK If BILLING ADDRESS <br /> FACILITY NAME Delapena Property, proposed residence <br /> SITE ADDRESS 3876 E. Emerson Rd. Acampo 95220 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) P.O. Box 1342 <br /> Street Number Street Name <br /> CITY Lodi STATE CA ZIP 95241. <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 280-5404 005-145-23 <br /> 11 <br /> PHONE#j Ext. BOS DISTRICT r LOCATIOAL,CODE <br /> --]I <br /> C50 <br /> CONTRACTOR / SERVICE REQUESTOR OL L11 <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 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: 0-j 2-1 Lu oc <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGER ❑ OTHER A UTHORIZED 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 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it i5 available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Nitrate Loading Study <br /> COMMENTS: <br /> May 21 �01�n <br /> QUIN GOON <br /> cvp,N JO R0%, <br /> ACCEPTED BY: C„ �(, EMPLOYEE#: DATE: <br /> ASSIGNED TO: J -�l EMPLOYEE#: DATE: <br /> Date Service Completed (if alr ady completed): SERVICE CODE: 5 Z� P I E: <br /> Fee Amount: b vo Amount Paid 3 C) Payment Date I , <br /> Payment Type C� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />