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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S ,SIERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Michael Armer CHECK if BILLING ADDRESS 0 <br /> FACILITY NAME Armer Property <br /> SITE ADDRESS 8891 W. Palmquist Ave. Tracy 95304 <br /> Street Number Direction I Street Name Ci ;in Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 8740 W. Vine Ln. <br /> Street Number Street Name <br /> CITY Tracy STATE CA ZIP 95304 <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (510) 331-1330 248-070-24 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK if BILLING ADDRESS O <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 /> CITY Lodi STATE CA z"'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 ort e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDER a <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNEA32�- OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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~MEWS <br /> provided to me or my representative. RECEIVE <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTME14T <br /> ACCEPTED BY: EMPLOYEE#: I DATE: -71 V311� <br /> ASSIGNED TO: �, EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE COD . P 1 <br /> 7,40 Z- <br /> Fee Amount: Amount Paid Z Payment Date 22, <br /> Payment Type Invoice# Check# 6) Received By: <br /> — WA <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />