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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 /> Jasdeep Singh & Harminder Kaur CHECK if BILLING ADDRESS X <br /> FACILITY NAME Singh / Kaur Trucking Facility <br /> SITE ADDRESS 3566 W. Eleventh St. Tracy 95304 <br /> Street Number Direction Street Name Cit ip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 25440 S. Schulte Rd. <br /> Street Number Street Name <br /> CITY Tracy STATE CA Zip 95377 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 640-1000 0239-060-18 PA-1700258 <br /> --71 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAx# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE CA Z'P 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 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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at th�}�Ie time it is <br /> provided to me or my representative. � 7� <br /> wr <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study ��`/ <br /> ll- <br /> COMMENTS: <br /> 69 <br /> �OVIHc ?0, <br /> MFHT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: AIJ�kl` <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P I E: 0-27, <br /> Fee Amount: Amount Pa i (�D�, �� Payment Date <br /> It Payment Type Invoice# Check# �Cf3 Rece. ed y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />