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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> `-�a <br /> OWNER/OPERATOR Ajay Kumar CHECK if BILLING ADDRESS <br /> FACILITY NAME Kumar Property <br /> SITE ADDRESS 11325W. Larch Rd. Tracy 95304 <br /> Street Number Direction Street Name I Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 420 Acoma Way <br /> Street Number Street Name <br /> CITY Fremont STATE CA zip 94539 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 510) 938-3070 212-180-23 , ---]1 <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 Geo Environmental 209 369-0375 <br /> HOME or MAILING ADDRESS Fax# <br /> 407 W. Oak St. <br /> ( ) <br /> CITY Lodi STATE CA z'P 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: 16A4 a DATE: (e- <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT P 6awfvL-1Yf-T <br /> If APPL/CANT 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. /gyp <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study <br /> COMMENTS: JUN 2 ;�-® <br /> 114N�0 12019 <br /> H FNS/R p�/H CO <br /> �'�GTyC�pM� �NTY <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �?j PIE:. v <br /> Fee Amount: O Amount Paid �,Z ,!�,o Payment 15ate <br /> Payment Type Invoice# Check# 5� Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />