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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S�032((�2 <br /> OWNER/OPERATOR <br /> Joe Bavaro CHECK If BILLING ADDRESS <br /> FACILITY NAME Bavaro Property <br /> SITE ADDRESS 19401 1 S. Dahlin Ave. Escalon 95320 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> P.O. Box 24 <br /> Street Number I <br /> Street Name <br /> CITY STATE ZIP <br /> Escalon CA 95320 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 595-1426 247-130-34 & -35 PA-1800194 <br /> PHONE#2 EXT. BOS DISTRICT11 LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <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, TATE and ERAL laws. l <br /> APPLICANT'S SIGNATURE: 0, DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 environmen 1/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at ,ty�time it is <br /> provided to me or my representative. R �ryryJJ4 <br /> 44 <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study FD <br /> COMMENTS: Sdo,, ? 2019 <br /> EA(v/ QIJIN <br /> N�CT D�pq���NTY <br /> NT <br /> ACCEPTED BY: G EMPLOYEE#: DATE: <br /> ASSIGNED TO: N 1 A <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ��� P1, 2�0-'L <br /> Fee Amount: �(� Amount P i 0gPayment Date �7 1 <br /> Payment Type Invoice# Check# ( J Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />