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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 9SEW� UEST# <br /> OWNER/OPERATOR T <br /> Lindsey Cox CHECK if BILLING ADDRESS <br /> FACILITY NAME Cox /Gatty Property <br /> SITE ADDRESS 30611 E. Edwards Ave. Oakdale 95361 <br /> Street Number Direction Street Name Citv 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) 679-9029 207-260-52 <br /> PHONE#2 EXT. BOS DISTRICT L� 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 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: DATE:�1�t�Z-�z0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MA GER ❑ 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, 1, 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 SIF <br /> COMMENTS: A <br /> EAly,!AQU/N <br /> 02020 <br /> hE4:THa p�17%L 7r <br /> ACCEPTED BY: �� EMPLOYEE#: DATE: 0 193 O <br /> ASSIGNED TO: EMPLOYEE#: DATE:r -�O a(jai <br /> Date Service Completed (if already completed): SERVICE CODE: 3 PIE: d 6Uo/ <br /> Fee Amount: C) Amount Paid n Payment Date <br /> Payment Typeav Invoice# Check# 5 -9-LJ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />