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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5'fzo i cog I q� <br /> OWNER I OPERATOR <br /> Susan Balogh/Jean Kent CHECK if BILLING ADDRESS <br /> FACILITY NAME Balogh/Kent Property <br /> SITE ADDRESS 19625 N. Southworth Rd. 952.40 <br /> sv etN tuber I LOdI <br /> ee N e L tic <br /> HOME Or MAILING ADDRESS (It Different from Site Address) P.O. Box 181 / 141 <br /> Sitmt NuIrwr Street Namc <br /> CITY <br /> Wallace STATE CA zip 95254 <br /> PHONE#i Exa APN# Lar JD USE APPLICATION# <br /> (209 ) 763-5253 023-260-01 N/A <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> ( 0 )763-5590 y <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Rocco CHECK if BILLING ADORE55EI <br /> BUSINESS NAME PHONE# E.T. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME Or MAILING ADDRESS FAC# <br /> 407 W. Oak St. ( 1 <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: I. the undersigned property or business onner, operator or authorized agent of same. <br /> acknou lL'dge that all site andlor project ,pecirle FNI'IRONNDiN`IAI.IIE.V.nI DEPART:NILI,I hourly charges associated pith this project <br /> or acro iry hill he hilted to me or my business as identified in this form. <br /> I also certil). dal I tare prepared this application and that the\\ork to he performed mill he done in accordance\Yith all SAN;JOAQUIN, <br /> Col-\-]'N !refinance!"odes.Stan(40 I.Sr IT..and Pia)1'R:u. 1 m, <br /> APPLICANT'S SIGNATURE:;� � I D.Vne: <br /> Pk01•!Ri\/BOSLN}SS0NNER20PERATOR/%1%1\6tk ❑ OruE :\rrnokv .NAt;ENr❑ <br /> Ij:I!'Pt.tt':LY7irtardtel3uu.rcPdt<T!.proof ojnrtlhorizariontosignisrequired Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When apphiwbic. I, the on ner or operator of the property located at the <br /> atone site address_ hemb% authorve the release of:mc and all results. g,eotechnncul data and/or enaironmentallsile a>srs.nlcnl <br /> inihrntatiun 10 the SA\*Jo:N(.tTN CI N'.NTy FNN1Ro\NIEN`I-.\L HEA1 Tit I)EPART'NOLNT as MKM aS it is acailahle and at (I H,Pr- I;mc �I r. <br /> prox ided to me or my representative. rHT MENT <br /> TYPE OF SERIACE REQUESTED: Review Surface & Subsurface Contamination Report Rt ` <br /> COMMENTSC T 0 1 U <br /> �,�•{.s,e l.tx` (tom V-.S� SAN JOAUUIN COL NTY <br /> ENVIROMENTA <br /> HEALTH DEPARTM ENT <br /> ACCEPTED BY: T ry� EMPLOYEE* ?VDATE: lD <br /> ASSIGNED TO: 44/ EMPLOYEE#: 4 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3/ S PIE: Z60 <br /> Fee Amount: Z�d �� Amount Paid Payment Date j3 <br /> Payment Type Invoice# Check# 7 Received B <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11(172003 <br />