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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�Do-�Gt01-S <br /> OWNER/OPERATOR <br /> Matthew Ng CHECK if BILLING ADDRESS <br /> FACILITY NAME Ng Property <br /> SITE ADDRESS 7670 E. Melton Rd. Manteca 95337 <br /> Street Number Direction I Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 16797S. Austin Rd. <br /> Street NumberT Street Name <br /> CITY Manteca STATE CA ZIP 95336 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION <br /> (209) 612-0132 257-220-37 <br /> PHONE#2 EXT. 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 Geo Environmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. l ) <br /> CITY Lodi STATE CA ZIP 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: 71&—z� DATE: 5-/T/1 `9 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGEDqo <br /> OTHER AUTHORIZED AGENT 0 ���GG/►z� <br /> If APPLICANT is not the BILLING PARTY,prouthorization 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 arjd at the same time it is <br /> provided to me or my representative. AY <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study ITSECES <br /> COMMENTS: AY �3 ?019 <br /> AN JOA Qu//V <br /> JV R�NM BOUNTY <br /> H�EpgRNTAC <br /> MENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: �5 PIE: Z 7Z <br /> Fee Amount: Amount Pai 7/_08 O-Z) Payment Date S�3 <br /> Payment Type ej Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />