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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ER ICE REQUEST# <br /> S ` /214q <br /> OWNER/OPERATOR <br /> Juana Rosas CHECK if BILLING ADDRESS E] <br /> FACILITY NAME Rosas Property <br /> SITE ADDRESS 1739 W. Piper PI. Tracy 95304 <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2384 Clemente Ln. <br /> Street Number Street Name <br /> c" Tracy STATE CA z'P 95377 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 275-9308 255-310-34 <br /> PHONE#2 EXT. BOS DISTRICT7T—�J LOCATION CODE? <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 /> c'n 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. <br /> APPLICANT'S SIGNATURE: r DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT �d>ISNI-lug <br /> IfAPPL/CANT 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 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. <br /> TYPE OF SERVICE REQUESTED: Review Nitrate Loading Study PAYMENT <br /> COMMENTS: RECEIVED <br /> (.l-N 0 2 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 3 Z Oa <br /> ASSIGNED TO: /\J4 EMPLOYEE#: DATE: J� <br /> Date Service Completed (if already Completed): SERVICE CODE: v�3 P I E: d 0r) <br /> Fee Amount: JSP Amount Paid Q Payment Date <br /> 47 41ao <br /> Payment TypeInvoice# Check# (5 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />