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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SF,0081I-so <br /> OWNER/OPERATOR <br /> Kusalakari Corporation CHECK if BILLING ADDRESS X❑ <br /> FACILITY NAME Kusalakari Property <br /> SITE ADDRESS 9698S. Priest Rd. French Camp 95231 <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different fro Site Address) <br /> CIO �rlan McNamara 53 Road 225 <br /> Street um er Street Name <br /> CITY North Fork STATE CA ZIP 93643 <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> (415) 293-9192 193-220-15 PA-1800177 <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 Geo Environmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <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 ED RAL laws. <br /> APPLICANT'S SIGNATURE: y` L 2�- DATE: ZU c) l Ck <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/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 environm tal/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and��time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study <br /> COMMENTS: SAJO <br /> NlgQ�lN Coij <br /> H�CTyDEPq���N)Y <br /> NT <br /> ACCEPTED BY: T' EMPLOYEE M DATE: <br /> ASSIGNED TO: 4 EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 23P 1 E:'g60?/ <br /> Fee Amount: Amount Paid 'Pd'r Payment Date <br /> Payment Typed Invoice# Check# 13"f3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />