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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 /> Gary Winters CHECK If BILLING ADDRESS El <br /> FACILITY NAME Winters Property <br /> SITE ADDRESS 6819 E. Lathrop Rd. Manteca 95336 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1272 E. Woodward Ave. <br /> Street Number Street Name <br /> CITY Manteca STATE CA ZIP 95337 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 471-5436 197-140-09 <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: 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, TE and FEDERAL haws. <br /> APPLICANT'S SIGNATURE: I DATE: — Ci D"e <br /> PROPERTY/BUSINESS OWNEROPERATO /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 andat the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study <br /> COMMENTS: s U N 2 8 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> V I iEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: �j DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: v� <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> , 73 PIE: a� <br /> Fee Amount: Amount Paid y O g _ Payment Date G <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />