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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 ba to <br /> OWNER/OPERATOR <br /> Danny & Maria Perugi CHECK if BILLING ADDRESSX❑ <br /> FACILITY NAME Perugi Property <br /> SITE ADDRESS 16588W. Los Positas Way Tracy 95304 <br /> Street Number Direction Sveet Name Ci 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• APN# LAND USE APPLICATION# <br /> (209) 649-3615 209-380-13 <br /> 7PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( l <br /> 11 1 dl <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 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 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, STATE and FEDERAL laws. 1 <br /> APPLICANT'S SIGNATURE: DATE: I <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 environmentaUsite 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. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Stud <br /> COMMENTS: <br /> RECEIVED <br /> JAN 2 7 2020 <br /> SAENVIRONMENTAL <br /> I <br /> TY <br /> ACCEPTED BY: EMPLOYEE#: HPAL DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (i already completed): SERVICE CODE: ?/ P I E: <br /> Fee Amount: ,��j Amount Paid () — Payment Date L264 <br /> Payment Type Invoice# Check# S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />