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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# G SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Azucena Duran Placencia CHECK If BILLING ADDRESSX❑ <br /> FACILITY NAME Duran Placencia Property <br /> SITE ADDRESS , Bird Rd. Tracy 95304 <br /> Street Number Direction Street Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 27625 S. Bird Rd. <br /> Street Number Street Name <br /> CITY Tracy STATE CA zip 95304 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 201-1714 239-190-19 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) 5 r3 6 <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 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: UA� DATE: <br /> PROPERTY/BUSINESS OWNERO 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 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 Study <br /> COMMENTS: !�G W t C' GI a e5 ivy ISL,V e G'1 o C1(1C�Y es 5. '�� <br /> PO Q <br /> J(/ <br /> sAN�o Z o 2020 <br /> FNt, Q�t <br /> y�FgRT o CNrY <br /> ACCEPTED BY:� Z Z� EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 7/�O d o,�(� <br /> Date Service Completed (if already completed): SERVICE CODE: S P 1 E: Q7 6 0 <br /> Fee Amount: 4(�o�' Amount Pa 600 0�) Payment Date � 2b <br /> Payment Type` Invoice# Check# —g� Recei d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />