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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 <br /> OWNER/OPERATOR <br /> Sargent Estates LLC (Margot Guis) CHECK ifBILUNGADDRESS <br /> O <br /> FACILITY NAME Sargent Equestrian Center <br /> SITE ADDRESS 15757E. Sargent Rd. Lodi 95240 <br /> Street Number Direction Street Name city ZiD 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. APN# LAND USE APPLICATION# <br /> (209) 727-0200 053-070-06, -07, -08 PA-1900129 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 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 7JP 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ' DATE: 11/8/2019 <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, herebyauthorize the release of any and all results, geotechnical data and/or environmentall//sij�assessment <br /> information to the SAN JOAQ UiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availabl� Id/ a time it is <br /> provided to me or my representative. ��►►ll ED <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study <br /> COMMENTS: VON <br /> UN cpuNTY <br /> SA EN ROtA �MV-Nl <br /> H�L.tH <br /> [De <br /> PPA, <br /> BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 6�� <br /> EeAunt: Amount Paid D Payment Date Type Invoice# Check# 2'� Re ived y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />