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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S9DCFsag55 <br /> OWNER/OPERATOR <br /> James Galarneau CHECK if BILLING ADDRESS <br /> FACILITY NAME Galarneau Property <br /> SITE ADDRESS 830 W. Woodbridge Rd. Lodi 95242 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) same <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> l 209► 327-8900 015-040-69 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ► <br /> co `/ 00� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnviron mental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE i- <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property 4�(A� of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HI �`�\� �s project <br /> or activity will be billed to me or my business as identified on this fon / l� <br /> -T \ VAS <br /> I also certify that I have prepared this application andth t the ork to ti // 2�r )AQUIN <br /> COUNTY Ordinance Codes,Standards,STATTEE'a o la s. <br /> APPLICANT'S SIGNATURE: y� <br /> — <br /> PROPERTY/BUSINESS OWNER O BATOR/,MAA R ❑ OTHE ✓' U` <br /> If APPLICANT is not the BILLIN(�-PARTY,proof of authorizatio <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable; he <br /> above site address, hereby authorize the release of any and all results, nt <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTI s <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loadil <br /> COMMENTS: <br /> �jo <br /> ?9 ?Of9 <br /> Aq <br /> `4 Nt pF MENlq� y <br /> ACCEPTED BY: EMPLOYEE#: DATE: _ _ 1 <br /> ASSIGNED TO: Ci lj-"- EMPLOYEE#: DATE: )Cl . <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid CPD 8 Payment Date `7 I2'q 1i9 <br /> Payment Type Invoice# Check# oZ�O y Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />