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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 0D�'—Z9W o <br /> OWNER/OPERATOR <br /> Harjinder Kahlon CHECK If BILLING ADDRESSEE] <br /> FACILITY NAME Kahlon Property <br /> SITE ADDRESS 21799 S Corral Hollow Rd. Tracy 95304 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1197 Tony Stuitt Dr. <br /> Street Number Street Name <br /> CITY Tracy STATE CA ZIP 95377 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 321-7425 212-260-02 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION 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. l ) <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 llawws. <br /> APPLICANT'S SIGNATURE: A� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® C-a"fyi�'1" <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. Ausfig <br /> NT <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/ Nitrate Loading Study V�® <br /> COMMENTS: <br /> NOV <br /> SANJOAQUN COUNTY <br /> ENVIRONMENTAL <br /> Hep,LTH DEPARTMENT <br /> ACCEPTED BY: � � EMPLOYEE#: DATE: I1 /a Q <br /> ASSIGNED TO: EMPLOYEE#: DATE: i I 10 c+a'd0 <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: 06001 <br /> Fee Amount: Amount Paid 4( b _ Payment Date b <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />