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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 /> Ramon Chicchon CHECK if BILLING ADDRESS <br /> FACILITY NAME Chicchon /Canton Property <br /> SITE ADDRESS 8623 Carey Ct. Stockton 95212 <br /> Street Number Direction Street Name Ci Zi 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) 938-8931 085-560-02 <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> ( ► <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: DA-rE: 1011;12D <br /> PROPERTY/BUSINESS OWNER❑ OPERA NAGER ❑ 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 R <br /> COMMENTS: <br /> OCT 13 2020 <br /> SAN JOAQUIN CO <br /> ENVIRONMENT,q� <br /> TY <br /> EALTy DEPARTMENT <br /> ACCEPTED BY: J��L EMPLOYEE DATE: lb 13apJD <br /> ASSIGNED TO: s. S EMPLOYEE M DATE: /0 13JO <br /> Date Service Completed (if already completed): SERVICE CODE: sa3 PIE: A C49 <br /> Fee Amount: Amount Paid Payment Date 1 L3 2,0 <br /> Payment Type Invoice# Check# / Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />