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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> U <br /> OWNER/OPERATOR <br /> Hacienda Estates (Kevin Phillips) CHECK if BILLING ADDRESS <br /> FACILITY NAME Hacienda Estates Lot 31 <br /> SITE ADDRESS 9501 E I Jahant Rd. Acampo 95220 <br /> Street Number I Direction Street Name Ci 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) 329-0574 007-310-31 <br /> PHONE#2 EXT. BOS DISTRICT 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, STAT d DERAL s <br /> APPLICANT'S SIGNATURE: DATE: L 2 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPL/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. <br /> TYPE OF SERVICE REQUESTED: , Review Soil Suitability Study, <br /> COMMENTS::-1 t,,1 )lot ;"' (rfr y <br /> r C rc4 PA^ DECEIVED J'-'�� <br /> OCT 0 2 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: � � EMPLOYEE#: D V <br /> ASSIGNED TO: .i EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S 3 P 1 E: d�0d <br /> Fee Amount: ';F 4 Amount Paid Payment Date l O aO <br /> C1 l <br /> Payment Type Invoice# Check# Received By: -�J <br /> REVISSEDED 111/17/2003 <br /> EHD SR FORM(Golden Rod) <br /> 1/1 <br />