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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 /> Christina Armosino CHECK N BILLING ADDRESS <br /> FACILITY NAME Armosino Property <br /> SITE ADDRESS 16724 S. Lawrence Rd. Escalon 95320 <br /> Street Number Di�e..�.. Strast Name City Zip Code <br /> HOME or MAILING ADDRESS (N Different from Site Address) 2346 Jessica Cir. <br /> Sheet Number Street Name <br /> CITY Escalon STATE CA ZIP 95320 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 679-9822 229-040-04 <br /> PHONIER En. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Rocco CHECK if BILLING ADDRESS <br /> BuslNEss NAME PHONE# <br /> Live Oak GeoEnvironmental (209 )369-0375 Exr. <br /> 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE CA z"'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,Standar&s�TTATE and FEDERAL laws. �i/� <br /> APPLICANT'S SIGNATURE:CZ� DATEA� /. .2012 <br /> PROPERTY/BUSINESS OWNER W OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> /,f APPLICANT lS not the BILLING PAR 7T Proof of authorization t0 sign IS required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 <br /> COMMENTS: Recle, 1 9 <br /> vev <br /> FEB 0 i -gig <br /> NVIRON N COUNTY <br /> ACCEPTED BY: EMPLOYEE#: �Afi'iriWg T <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: l jv P 1 E: Z <br /> Fee Amount O Amount Paid 0 g ,UO I Payment Date -Z t t <br /> Payment Type OJM41Invoice# Check# :�LO Co Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />