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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />c koffoprt <br />OWNER / OPERATOR <br />Fred Smith CHECK if BILLING ADDRESS x <br />FACILITY NAME Smith Property <br />SITE ADDRESS 4219 <br />Street Number <br />E. <br />Direction <br />Bluestone Ct. <br />Street Name <br />Acampo <br />City <br />95220 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 24740 <br />Street Number <br />N. Sowles Rd. <br />Street Name <br />CITY STATE ZIP Acampo CA 95220 <br />PHONE #1 EXT. <br />( 209) 329-3718 <br />APN # <br />005-360-09 <br />LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE <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 STATE Lodi Zi ZIP 95240 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, S TE and kEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br /> <br />PROPERTY / BUSINESS OWNER!: OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <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. <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study R8CE1761Vor <br />COMMENTS: <br />JUL 0 2 <br />4 20/9 SAN , <br />tir...NV/Roi,v,,llv COuiv ry <br />cdiLTH DEpfigENTAL <br />ARrwNT <br />ACCEPTED BY: 14- EMPLOYEE #: <br />EMPLOYEE #: DATE: iAliT DATE: <br />ASSIGNED TO: <br />Date Service Completed(if already completed): SERVICE CODE: -73 P1 E;7102/ <br />Fee Amount: 4.b, t Amount PaO ‘,070.0 Payment Date 7/3/7 <br />Payment Type de_ Invoice # Check # .2../ 71 Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)