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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C, <br /> OWNER/OPERATOR Kim Affonso CHECK if BILLING ADDRESS 0 <br /> FACILITY NAME Affonso Property <br /> SITE ADDRESS 1424 S. Jack Tone Rd. Stockton 95215 <br /> Street Number I Direction Street Name cilL Zio 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) 456-1247 183-020-08 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <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 /> ( ) <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,Standar , STATE and FEDE L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERA R NAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPL/CANT is not the BILLING ARTY,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 Soil Suitability Nitrate LO <br /> COMMENTS: l vpn SUN 15 <br /> ILZ <br /> � 2020 <br /> JUN 15 2020 EMPEONM6 <br /> Ely iR p�INCOtJN RMIr�SERVIC SETH <br /> kEALTy p p4 A il' <br /> ACCEPTED BY: `7� L EMPLOYEE M DATE: �6- ZO Z-0 <br /> ASSIGNED TO: s ^1-4 EMPLOYEE M DATE: (; � <br /> Date Service Completed (if already completed): SERVICE CODE: 3 PIE: a 6 J <br /> VA <br /> Fee Amount: t} Amount Paid ��" Payment Date <br /> Payment Type Invoice# Check# J I Received By: <br /> EHD 48-02-025AAOO <br /> SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />