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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 1 OPERATOR <br /> Dylan Foster CHECK if BILLING ADDRESS <br /> FACILITY NAME Foster Property, proposed new home <br /> SITE ADDRESS 30566 E. Hall Ave. Escalon 95320 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 6243Jaguar Ct. <br /> Street Number Street Name <br /> CITY Riverbank STATE CA ZIP 95367 <br /> PHONE#1 EZT. APN# LAND USE APPLICATION# <br /> (209) 485-1718 249-080-22 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) ;� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Rocco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EZT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <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 /> / <br /> APPLICANT'S SIGNATURE: (/f/j� A/!:'//\ DATE: 2- -2 to -1 k, <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHOmmo AGENT R9 f.ONI'I/IT <br /> If APPLtCANT is not the BILLING PAR TP proof of authorization to sign is required Tine <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 envirommental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and aT�t}te same time it is <br /> provided to me or my representative. A Y <br /> TYPE OF SERVICE REQUESTED: Review Nitrate Loading Study IiQCF r <br /> COMMENTS: B rl <br /> y���F MIEN �OJ� <br /> ARrMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: QhfiL-ed EMPLOYEE M DATE: 2 / <br /> Date Service Completed (if already completed): SERVICECODE: E: �� <br /> Fee Amount: ::.)O O(� Amount Paid D� Payment Date z /y 44 <br /> Payment Type �� invoice# Check# M Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />