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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> b 0 qq ko <br /> OWNER/OPERATOR <br /> MJDA Properties, LLC (Al Caton) CHECK If BILLING ADDRESS X <br /> FACILITYNAME MJDA Properties <br /> SITE ADDRESS 14503 S. Campbell Ave. Escalon 95320 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 14907 S. Campbell Ave. <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Esc llon CA 95320 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 48,:i-3457 207-320-12 & -21 <br /> PHONE#2 EXT. BOS DISTRICT l{ 7�ODE „_ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> A Eby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Lite Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> c'T" Lodi STATE CA Z'P 95240 <br /> BILLING ACKNO_',"LEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all ?ite and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be bille'to me or my business as identified on this form. <br /> I also certify that I havt prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Cot s,Standards,STA an EDE la s. <br /> APPLICANT'SSIGNA URE: DATE: 1112 2r-)Z0 <br /> PROPERTY/BUSINESS OWNY:❑ OPERATOR/MANAGER. OTHER AUTHORIZED AGENT❑ <br /> IfAPPL7ClNT is not the BILLING PAR77,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, hereb authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAO'JIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my repres,r.tative. <br /> TYPE OF SERVICE REQUESTED: - Review Surface & Subsurface Contamination Report R y. <br /> COMMENTS: ao <br /> D <br /> y Fih,°go�, ?0 <br /> �cMq f, <br /> M <br /> ACCEPTED BY: /•�f��� EMPLOYEEM DATE: <br /> ASSIGNED TO: S EMPLOYEE M DATE: lob 03 7ap.ZU <br /> Date Service Completed (if already-ompleted): SERVICE CODE: 3 P i E: p �� <br /> Fee Amount: 4 30L1Amount Pai 00 Payment Date L2� <br /> Payment Type Invi ice# Check# f`3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />