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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 00vzss- - <br /> OWNER/OPERATOR <br /> German Jimenez CHECK if BILLING ADDRESS X <br /> FACILITY NAME Jimenez Property <br /> SITE ADDRESS 124 W. I Briggs Rd. Lathrop 95330 <br /> Street Number I Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) same <br /> Street NumberT Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 305-2066 193-330-37 <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 /> 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 FEDE laws. <br /> APPLICANT'S SIGNATURE: C-7c' <br /> DATE' <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 environmental/site assessment <br /> information t0 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. dw <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Nitrate Loading Study A <br /> COMMENTS: <br /> -SAN do, <br /> ?? ?020 <br /> Eiy�,AQUiy <br /> NrHbip Fti�AUH� <br /> ACCEPTED BY: �1� EMPLOYEE#: DATE: <br /> � as a�ao <br /> ASSIGNED TO: NA EMPLOYEE#: DATE: 7/fid Jai <br /> Date Service Completed (if already completed): SERVICE CODE: Sd 3 P 1 E: d Eva <br /> Fee Amount: -4 (_,C F Amount Paid D Payment Date 20 <br /> s <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />