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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA ✓ <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Singh, Bachitar & Jaswinder et al. CHECK if BILLING ADDRESS x❑ <br /> FAclU YNAME Profleet Truck Lube & Tire Service <br /> SITE ADDRESS 24511 1 Highway 99 W. Frontage Rd. Acampo 95220 <br /> Street Number rill u o Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 15453 N. Thornton Rd. <br /> c/oProfleet Truck & Lube Street Number Street Name <br /> CITY Lodi STATE CA ZIP 95242 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (209) 327-2836 Bachitar Singh 005-160-15 & -19 PA-1600008 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION C DE <br /> ( 7D9 ) 333 - 8353 a;C. ,Aaa <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK It BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex . <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAz# <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 1IEALTH 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 andE laws. <br /> APPLICANT'S SIGNATUR�IE: \ DATE: s 7 <br /> -FRoPERTY/BUSINESS OWNER; OPE \T�/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PART P proofofauthorization 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 environmentaUUQite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at t11e it is <br /> provided to me or my representative. dQ <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate <br /> Loading Study <br /> COMMENTS: '0I/11-7 / S V'lo iryC 2OlI <br /> hfAtTH p f�Mft, 7'1, <br /> n. <br /> ACCEPTED BY: 41 <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: -0 EMPLOYEE#: DATE: 5--2, - l err <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date �c� `-7 <br /> Payment Type C Invoice# Check# Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />