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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUE T# <br /> OWNER/OPERATOR <br /> Eddie & Rosa McCormick CHECK if BILLING ADDRESS <br /> FACILITY NAME McCormick Property <br /> SITE ADDRESS 3657 S. Pock Ln. Stockton 95205 <br /> Street Number I Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2538 Deborah Ln. <br /> Street Number Street Name <br /> CITY Stockton STATE CA Zip 95206 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (760) 382-0847 179-140-04 <br /> T— <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) C <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. I <br /> APPLICANT'S SIGNATURE: <br /> /��'l� DATE' <br /> PROPERTY/BUSINESS OWNER OP—ERA-TO-RI-/,MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/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. p <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability / Nitrate Loading Study T <br /> COMMENTS: VkZ_ <br /> SAN / 6 2021 <br /> OA <br /> H E�RON�CC N <br /> �Ty <br /> ACCEPTED BY: �— EMPLOYEE#: DATE: <br /> ASSIGNED TO: S EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: ��C <br /> Fee Amount: 0 c'� Amount Paid 4, Payment Date � �CC 2i <br /> Payment Type LC Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />