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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S ERVICE REQUEST#�� <br /> LD A, <br /> OWNER/OPERATOR <br /> Merry Ann & Art Gomez CHECK if BILLING ADDRESS X❑ <br /> FACILITY NAME Gomez Property <br /> SITE ADDRESS 3809 E. Emerson Rd. Acampo 95220 <br /> Street Number Direction I Street Name I Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 24832 N. Elliott Rd. <br /> Street Number Street Name <br /> CITY Acampo STATE CA zip 95220 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 265-6615 005-145-11 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION C DE <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 /> ( ) <br /> C'n 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;/I&az ZZ, — <br /> d <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 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 the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study CEIVED <br /> COMMENTS: MAY 2 8 2019 <br /> SAN JOAQUIN COUNTY <br /> O � ENVIRONMENTAL <br /> A� HEALTH DEPARTMENT <br /> V ACCEPTED BY: !1!2&AEMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S P i <br /> Fee Amount: Amount Paid (X�Cj,� Payment Date 62�( I <br /> Payment Type Invoice# Check# I l) Received By: vF� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />