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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property S 8008 ( 3a t <br /> Agricultural <br /> CHECK If BILLIN�E� <br /> OWNER!OPERATOR <br /> Grewal Revocable Trust <br /> FAcarn'NAME 95304 <br /> W Tracy Z; code <br /> SITE ADDRESS 4700 Lovely Road city <br /> Sven Number Direction Street Named <br /> HOME or MAILING ADDRESS of Different from Site Address) 5455 West Durham Ferry Road <br /> Street Name <br /> Street NumherE ZIP <br /> crTr STATE CA 95304 <br /> Tracy <br /> Ear APN 0 LAND USE APPLICATION# <br /> PHONE 01 <br /> (209) 676-1846 250-100-13 NSA LOCATION CODE <br /> PBOS DISTRICT <br /> HONE#2 Ear. <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK 11 BILUN <br /> G ADDRESS <br /> �►�(5H5�-�-c9F� EXT. <br /> PH�AE# / 1 <br /> BUSINESS NAME I'y �E <br /> W Y\ l rJ 1 l �c FAx# <br /> HOME or MAILING ADDRESS / �f Yl(�1 ( I �f <br /> b II�vi�j a STATE C_ ZIP <br /> QJg v <br /> CITY L <br /> Tit of same, <br /> BILLING ACKNOWLEDGEMENT: I. the undersigned property or business owner, operator or authorized age <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEP.ARTb4ET1T 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 app ation d that the work to be ertormed will be done in accordance with all SAN JOAQUIN <br /> CouN*T}r Ordinance Codes,Standards,ST and EDERAL I s. <br /> ftra <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERn'/BUSINESS OWNER❑ OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT <br /> fAPPLICAA7 is not the BILLP.VG 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. Mf MENT� <br /> TYPE OFSEAVICEREQUESTED: Soil Suitability/Nitrate Loading Studies Review <br /> CONNENTS. /I// �e uZ'J'� <br /> 5 201 <br /> SAN Jo#,QUIN COU TY <br /> ENVIRONMENT <br /> HEALTH DEPARTM NT <br /> ACCEPTED BY: EMPLOYEE M fvl DATE: 10 7 l^ <br /> ASSIGNED TO: C /K)o EMPLOYEE M Y DATE: W <br /> Date Service Completed (if already completed): SERVICE CODE: Z P I E: 2 O <br /> Fee Amount O Amount Paid b — Payment Date C �� <br /> Payment Type Invoice# Check# <br /> 7/S�v Received By: / <br /> EHD 48-02-025 <br /> REVISED 11/17/20013 SR FORM (Golden Rr, <br />