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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />G(. WW1, 50 <br />OWNER / OPERATOR <br />Mike Wutzke CHECK if BILLING ADDRESS X <br />FACILITY NAME Wutzke Property <br />SITE ADDRESS 21600 <br />Street Number <br />N. <br />D.,...„,,,, <br />Kennefick Rd. <br />Street Name <br />Acampo <br />City <br />95220 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) same <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( 209 ) 642-5659 <br />APN # <br />017-150-36 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT 4 LOCATION CAE q-/ <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 FE RAL law <br />APPLICANT'S SIGNATURE: >72,e DATE: <br />OTHER AUTHORIZED AGENT 0 PROPERTY! BUSINESS OWNER!: OPERATOR! MANAGE <br /> <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 the same time it is <br />provided to me or my representative. PAYMENT <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study RECEIVED <br />COMMENTS: <br />JUL 2 6 2019 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: 41-lik EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 9-2/5 P I E: 02/ <br />Fee Amount: j7 ,irdo Amount Paid # 0 --- Payment Date --4(2 /Z22.7 <br />Payment Type V i ".., Invoice # C'll # al q (Cj (i 3i 2,zc Received By: <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003