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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0(��&Z5 U <br /> OWNER/OPERATOR <br /> Cindy & Keith Nienhuis CHECK If BILLING ADDRESS <br /> FACILITY NAME Nienhuis Property <br /> SITE ADDRESS 5828 E. Fairlane Rd. FAcampo 95220 <br /> Street Number I Direction Street Name citv <br /> Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 707 Summit Lakes Way <br /> Street Number Street Name <br /> CITY Galt STATE CA ZIP 95632 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 747-4868 005-270-15 <br /> PHONE#2 EXT• BOS DIST R CT LOCATJON 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 /> 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: tJo <br /> DATE: I <br /> PROPERTY/BUSINESS OWNER 121 OPERA R/MANAGER ❑ OTHER AUTHORIZED AGENT (LAe-I- <br /> o <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. P <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Nitrate Loading Study e, T <br /> COMMENTS: sop <br /> WIZ <br /> NRo U1N CD OZ� <br /> E'4CTy�pM����Ty <br /> A 12 <br /> ACCEPTED BY: / EMPLOYEE M DATE: Ct I Z0 <br /> ASSIGNED TO: �{ EMPLOYEE M DATE: 01rt � <br /> Date Service Completed (if already completed : SERVICE CODE: L� Z _P(/E: <br /> Fee Amount: Amount Pai � Payment Date 26 <br /> Payment Type 0 Invoice# Check# ( Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />