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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SF-00Ice637 <br /> OWNER/OPERATOR <br /> Abdul Chashmawala CHECK if BILLING ADDRESS X <br /> FACILITY NAME Chashmawala Property <br /> SITE ADDRESS 255087 S. I Lammers Rd. Tracy <br /> Street Number I DI-11 a Street Name ciiy I Zip Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 62552 Chesapeake Cir. <br /> c/o Dean Gilman Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95219 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (209 ) 483-2960 209-250-41 <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# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. (209 )369-0377 <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: yr~ DATE: i`L"L/) (42 <br /> PROPERTY/BUSINESS OWNER, OPERATOR/MANAGER OTHER AUTHORIZED AGENTâť‘ <br /> If APPLICANT is not the BILL/NC PARTY proof of authorization t0 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/Nitrate Loading Study pAYMENT <br /> COMMENTS: RECEIVED <br /> '/3///7 DEC 3 0 2016 <br /> 1 SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT' <br /> ACCEPTED BY: EMPLOYEE#: DATE:log <br /> ASSIGNED TO: I is j EMPLOYEE M DATE:tiz t ' <br /> Date Service Completed (if already ompleted): SERVICE CODE: PIE: V v <br /> Fee Amount: 14 Amount Paid oc, Tayment Date :36 1/10 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />