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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST# <br /> SI2U06�4(� <br /> OWNER/OPERATOR <br /> Manuel Tavares CHECK if BILLING ADDRESS <br /> FAGUTr NAME Tavares Property <br /> SITE AD1S. North Ripon Rd. Ripon <br /> 1996642 DI& 19�5� <br /> Street um r tteontrC ZI code <br /> HOME Of MAILING ADDRESS (If Different from Site Address) P.O. Box 1145 <br /> Street Number Street m <br /> CITY Ripon STATE CA ZIP 95366 <br /> RHONE#1 Err. APN# LAND USE APPLICATION# <br /> (209 ) 740-0203 245-150-01 PA-1300141 <br /> PHONE#2 Er' BOS DISTRICT LOCATION CODE <br /> ( I J04- <br /> CONTRACTOR <br /> U CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRF55E] <br /> BUSINESS NAME Live Oak GeoEnvironmental Pl2OE9# EXT <br /> HOME <br /> 369-0375 <br /> HOME or MAILING ADDRESS FAIL# <br /> 407 W. Oak St. I ( l <br /> CITY Lodi STATE CA LP 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 JoAQErIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL,laws. <br /> APPLICANTS SIGNATURE: ' C1cJU W140 DATE: <br /> Pleopsim/BusemssowNERE3 OPERATOR/MANAGER o OTmOtArrmoRIzRDAGENT O <br /> V'AP'LicANT is not the B![gNG P,aaTr proof of authorkation to sign is required Titre <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,the owner or operator of the property located at the <br /> abm'e site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite 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 W me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review SOLI SuitabilitV ,Stud <br /> COMMENTS: <br /> R„t, -�as,.,.��j curt cy„ t +� f� I`1 sary�oq2014 <br /> iY Ely yrR UIl y CO <br /> �lTjt aEMEN �UAryy <br /> ACCEPTED BY: EMPLOYEE#: 2-6 7 DATE: ///S//(/- <br /> ASSIGNED TO: Y' EMPLOYEE#: (�S DATE: <br /> Date Service Completed Of already competed): SERVICE CODE: S'Z Z P/E: Z <br /> Fee Amount. �'Z 52) Amount Pal a D� Payment Date S / <br /> Payment Type Invoice# Check# 1�Z3 Received By. <br /> EHE)48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />