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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />0 (0 q I .400 <br /> <br />OWNER / OPERATOR <br />Jerry & Linda Madzier CHECK if BILLING ADDRESS x <br />FACILITY NAME Madzier Property <br />SITE ADDRESS 11006 <br />Street Number <br />E. <br />Direction <br />St. Rt. 120 <br />Street Name <br />Manteca <br />City <br />95336 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 2204 <br />Street Number <br />E. Yosemite Ave. <br />Street Name <br />CITY STATE ZIP Manteca CA 95336 <br />PHONE #1 Exr. <br />( 209) 823-1751 <br />APN # <br />228-030-26 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br />(ft <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Abby Racco CHECK if BILLING ADDRESS <br />BUSINESS NAME Oak GeoEnvironmental <br />EXT. <br />Live <br />PHONE # <br />(209 )369-0375 <br />HOME or MAILING ADDRESS <br />407 W. Oak St. <br />FAX # <br />( ) <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 /> DATE: 6* <br />N.C/VECI TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study JUN <br />COMMENTS:nin 0 3 2 <br />CL.-00 '" 00 Z-_,' SAN j, `"v/.7 <br />hatiroA,A,A;c014,, <br />H ()EPA asENN. <br />' <br />ACCEPTED BY: I EMPLOYEE #: VC DATE: _3 % <br />ASSIGNED TO: <br />--5e Ql) 0 AC\ <br />EMPLOYEE #: DATE: <br />Date Service Completed (if already conipleted): SERVICE CODE: 4.5- 2: PIE: 2, 6 02_ <br />Fee Amount: Amount Pa6 .Y. 61, Payment Date 0/3M <br />Payment Type Invoice # Check # 47.2z)0 Z262 Received Byvi/S)___ <br />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER 0 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 time it is <br />provided to me or my representative. <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003