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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '- Do y <br /> OWNER OPERATOR Amar Mathfallu CNEcvcifBILLING ADoREss x❑ <br /> FACIUrYNAME Ash & Veer Enterprises Property <br /> SITE ADDRESS 18787& iggi N, Highway 99 W. Frontage Rd. Acampo 95220 <br /> S Nu <br /> HOME or MAILING ADDRESS IN DMerent from Site Address) 18915 N. Highway 99 W. Frontage Rd. <br /> Veal Numberstmet N.. <br /> CITY Acampo STATE CA LP 95220 <br /> PHONE#1 E)T' APN# LAND USE APPLICATION# <br /> (209) 481-2627 013-220-16 AA - /Y_ Z--3t�C�rJs <br /> PHONE ICL En. BOB DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco <br /> CHECK H BILLING ADDRESS <br /> BUSINESS NAME PNONE# <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 7,"95240 <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 JOAQUIN <br /> COUNTY Ordinance Codes,Standar TATE and <br /> FEDERAL la <br /> APPLICANT'SSIGNATURE� //i//L:# DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTnoitlzm AGENT 13 <br /> IfAPPLICANT is not the BILLING PAR 7T proof of authorization to 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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available ar ylylLn>fle it is <br /> provided to me or my representative. E X11 G�`I � <br /> GEIVED <br /> TYPE OF SERVICE REQUESTED: Review Soil .Suitability .Study <br /> COMMENTS: n yg/�S ( i.. <br /> j? I'r7 L7 f2wltk)r� SAN JOAQUIN COUNTY <br /> /J'J F. ESCFii � ENVIROMENTAL <br /> /Jtw� HEALTH DEPARTMENT <br /> ACCEPTED BY: ( EMPLOYEE#: DATE: W10)'(57 <br /> (S <br /> ASSIGNED TO: II[D , EMPLOYEE#: DATE:01IC)l 157 <br /> Date Service Completed (H already completed): SERVICE CODE: Jr" �a PIE: �c+�I <br /> Fee Amount: [),00 Amount Paid ( (' C) Payment Date 7 Y Q Y <br /> Payment Typec(ge Invoice# Check# Received By:l�J <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />