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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 5�myo <br /> SERVVICEE REQUEST# <br /> 0U <br /> OWNER/OPERATOR <br /> Frank Kooger CHECK if BILLING ADDRESS <br /> FACILITY NAME Kooger Property <br /> SITE ADDRESS 3149 E.tion Collier Rd. Acampo 95220 <br /> Street Number DirecStreet Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( > 005-370-27 <br /> --7�PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK if BILLING ADDRESS❑ <br /> EXT. <br /> BUSINESS NAME Live Oak GeoEnvironmental PHONE209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE CA z'P 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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,la s. <br /> APPLICANT'S SIGNATURE: ✓�J\I DATE: Co Z - Lo l�j <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 the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study <br /> COMMENTS: /J � � 1 _ <br /> ��./ Jul <br /> Jo ?5 ?p <br /> H�LTy DONMFN U <br /> FpyRT TAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: L <br /> ASSIGNED TO: (L. EMPLOYEE#: DATE: v <br /> Date Service Completed (if already completed): SERVICE CODE: e—Z-,3 P E: Z40 Z <br /> Fee Amount: 6 Amount Pa' 0 Payment Date �. <br /> Payment Type Invoice# Check# 307 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />