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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Greenhouse <br /> OWNER/OPERATOR h <br /> aceu <br /> Rachel LiO <br /> I Hsin Orchids,Inc. CHECK If BILLING ADDRESSILY <br /> FACILITY NAME I Hsin Orchids,Inc. <br /> SITE ADDRESS 122w <br /> Hamey Ln Lodi 95245 <br /> Street Number I Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 509-9524 r L G. <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) ( r <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR John Vierra CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME NJA Architecture PHONE# 209.610.6036 Ems' <br /> HOME or MAILING ADDRESS2t'_ %t, P I I I C St :' I. Suit' I FAX# <br /> CITY i .II 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 /> 1 also certify that I have prepared this ap cati n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards TAT FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 09.01.20 <br /> PROPERTY/BUSINESS OWNER❑ P .2 ATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Architect <br /> 1f'APPLIC9NT 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: So <br /> COMMENTS: IV <br /> Review of nitrate study AY)dSof SIJ >�6+ I — ejyp1Q� F�V <br /> SFp 03 F <br /> I SAN�o ?OZ� <br /> hFg4TNoPNT <br /> ACCEPTED BY: ^�' l� EMPLOYEE#: DATE: �/a to �l r <br /> ASSIGNED TO: EMPLOYEE#: DATE: Oldho'go <br /> Date Service Completed (If already completed): SERVICE CODE: "r l PIE: d(—Od <br /> Fee Amount: OF Amount Pai 0� Payment Date L3, 2O <br /> Payment Type Invoice# Check# 11L5 g 2 S� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />