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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR / <br /> Roopa Delapena CHECK if BILLING ADDRESS <br /> FACILITY NAME Delapena Property <br /> SITE ADDRESS N. Sadlerstone Dr. Acampo 95220 <br /> GI ( Street Number Direction Street Name Ci 2i 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) 280-5404 005-360-15 <br /> PHONE#2 EXT. BOS DISTRICT j LOCATION CODE <br /> ( ) �i r r� <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:L_ X DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 0 4 <br /> 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. 1 1 f <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study 3 <br /> COMMENTS: CV� <br /> SEP O y D <br /> 2020 <br /> S N 0q <br /> QN <br /> HFqLTH E UIC MENTq NTY <br /> ACCEPTED BY: �� fjl l EMPLOYEEDATE: �� / wNT <br /> ASSIGNED TO: /,,,I EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: a 3 P IE: C?C Vol <br /> Fee Amount: 4, DF Amount Pa' 0-0Payment Date 2,z> <br /> Payment Type Invoice# Check# /d Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />