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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> j2Gb75-J S"7 <br /> OWNER/OPERATOR Antonette Silva CHECK If BILLING ADDRESSx❑ <br /> FACIUTYNAME Silva Property <br /> SITETSADpgE 8447, 18459 E. Highway 120 Ripon 95366 <br /> I t S t Number Direcllon Street Name CIW Zip Code <br /> HOME Or MA DDRESS (If Different from Site Address) 18459 E. Highway 120 <br /> Street NumberStreet Name <br /> CITY Ripon STATE CA ZIP 95366 <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (209 ) 988-7977 205-070-39 &00 <br /> PHONE#2 F-aT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESSI� <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental (209 )369-0375 <br /> HOME Or MAILING ADDRESS 407 W. Oak St. (209)369-0377 <br /> CITY Lodi STATE CA LP95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 JOAQu1N <br /> COUNTY Ordinance Codes,Standards,STATE and FE9qAL laws. <br /> APPLICANT'S SIGNATURE: IL DATES:I 1 -6 -/ e <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER OTHER AUTHORIZED AGENT LSI CoNSVLTkNT <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 environ mentausiteormation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sarA,� <br /> provided to me or my representative. AMClhhh!!jut ,,ctrl <br /> TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report Jy( 0 <br /> C MENTS: I,� Lj AN jOgQUI <br /> /llY���,,,,�- �r;l p� ,;INC <br /> p (/�►nr <br /> 11 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (i already completed): SERVICE CODE: 5Z 7J PIE: Z[p0�j <br /> Fee Amount: Amount Pai o2� ob Payment Date 7 <br /> Payment Type Invoice# Check# S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />