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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 /> Aleck Dambacher CHECK If BILLING ADDRESS <br /> FACIUTYNAME Dambacher Property <br /> SITE ADDRESS 27445 N. New Hope Rd. Thornton 95686 <br /> Street Number Dil—I.— I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) P.O. Box 678 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Thornton CA 95686 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (9161425-6406 001-210-33 PA-1500256 <br /> PHONE#2 ExT. BOS DISTRIC LOCATION CODE <br /> ( ) ®04 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <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 ENVIRONmIENTAL 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 ap licatio and tha�®-wot�l o be performed will be done in accordance with all SAN JOAQUIN <br /> CouNTY Ordinance Codes,Standar T 17laws. / <br /> APPLICANT'S SIGNATURE: DATE: / -3 1J <br /> PROPERTY/BusTNEss OWNER OPERATOR/M AGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IrAPPLICANT is not the BILLING 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/ise assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tl}@ s ! it is <br /> provided to me or my representative. F ^/?' <br /> If <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study $q��F�C o <br /> COMMENTS: n r �"�'✓ONQU/ ?018 <br /> �O t S 20X_ A > l E haUt�i-� X14 H�417,li V COUN� <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1 a n!1 EMPLOYEE#: DATE: <br /> Date Service Completed already com ted): SERVICE CODE: S Z3 P I E: <br /> Fee Amount: o(� Amount P"10 30 OD Payment Date f <br /> Payment Type Invoice# Check# 'JOOZ Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />