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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 /> Ford Construction Co. (Nick Jones) CHECK if BILLING ADDRESS X <br /> FACILITY NAME Ford Construction Facility <br /> SITE ADDRESS 12505E. Brandt Rd. Lockeford 95237 <br /> Street Number Direction Street Name Ci ip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 300 W. Pine St. <br /> Street Number Street Name <br /> CITY Lodi STATE CA ZIP 94240 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 333-1116 051-320-10 PA-1800204 <br /> --71PHONE#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 GeoEnviron mental 209 369-0375 <br /> HOME or MAILING ADDRESS FAx# <br /> 407 W. Oak St. ( ) <br /> C'TY 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 Oplication and Nt the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S TE and l -s <br /> laws. <br /> APPLICANT'S SIGNATURE: l�- DATE: �'23► ly <br /> PROPERTY/BUSINESS OWNER❑ ORATOR/MANA E ❑ OTHER AUTHORIZED AGENT ElIf APPLICANT is not the BILLING PARTY pro 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 t0 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study RECEIVE® <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: ha <br /> ASSIGNED TO: O EMPLOYEE#: DATE: <br /> Date Service C pleted (if already completed): SERVICE CODE: P 1 E <br /> Fee Amount: Amount Paid C) _ Payment Date 2 / l <br /> Payment Type Invoice# Check# / Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />