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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 /> Brittany Farris CHECK if BILLING ADDRESS Li.2JX <br /> FACILITY NAME Farris Property <br /> SITE ADDRESS S. Carrolton Rd. Ripon 95366 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 13293 E. Louise Ave. <br /> Street Number Street Name <br /> CITY Manteca STATE CA z'P 95336 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (209) 481-0807 245-070-89 <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 Geo Environmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( 1 <br /> CITY Lodi STATE CA z'P 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 FEDERAL laws. 1 <br /> APPLICANT'S SIGNATURE: DATE: )I.— ;Zl� I S <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTFIORIZEu AGENT❑ <br /> IfAPPL/CANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 d at the same time it is <br /> provided to me or my representative. '' <br /> TYPE OF SERVICE REQUESTED: Review Nitrate Loading Study <br /> COMMENTS: (, <br /> h FNI/0, <br /> �94Ty%FpgRT OQNry <br /> MFNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M ' DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E. <br /> Fee Amount: Amount Pal Payment to I <br /> Payment Type Invoice# Check# / Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />