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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S RVICE REQUEST# <br /> rVAN <br /> OWNER/OPERATOR <br /> Felix Jaimes CHECK if BILLING ADDRESS <br /> FACILITY NAME Jaimes Property <br /> —7 <br /> SITE ADDRESS 10331 N. St. Rt. 99 W. Frontage Rd. -Stockton 95212 <br /> Street Number Direction S <br /> treet Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 8712 <br /> Street Number LOS OIIVOS Ct. Street Name <br /> CITY STATE ZIP <br /> Stockton CA 94210 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 641-4251 122-030-08 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> a q� <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. ( ) <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 e work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard STA and FEDE L laws. <br /> APPLICANT'S SIGNATURE. DATE: D 102-12,1 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANA R ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANt is no he 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/ Nitrate Loading Study RECEIVED <br /> COMMENTS: FEB 0 2 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 0-1 3i <br /> ASSIGNED TO: C < EMPLOYEE#: DATE: a <br /> Date Service Completed (if already completed): SERVICE CODE: S,)3 P 1 E: 076012 <br /> Fee Amount: G,v Amount Paid 60, tD — Payment Date 2 -7 <br /> Payment Type /0JL Invoice# Check# 2 �- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />