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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 0jSERVICE REQUEST#, <br /> 0rv-jU 0 3C)q'--%7 <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS El <br /> MJDA Properties, LLC (Al Caton) <br /> FACILOTY NAME MJDA Properties <br /> SITE ADDRESS 14503 1 S. Campbell Ave. Escalon 95320 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 14907 S. Campbell Ave. <br /> Street Number Street Name <br /> CIS. STATE ZIP <br /> Escalon CA 95320 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 480-3457 207-320-12 & -21 PA-2 kx0o,5-6VS) <br /> PHONE#Z EXT BOS DISTRICT LOCATION CODE <br /> ( ) <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 zIP 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 EDERAL laws. i <br /> APPLICANT'S SIGNATURE: DATE: /'?h Z: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study AYM <br /> COMMENTS: EII/Ep <br /> 2 8 2020 <br /> SAN JOAQUIN COUNTY <br /> il&ogL y p NMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: Iala��p';t <br /> ASSIGNED TO: S s EMPLOYEE#: DATE: I AJd yld pia <br /> Date Service Completed (if already completed): SERVICE CODE: S,�3 P I E: a 6p� <br /> Fee Amount: �O Amount Paid / Payment Date 1 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Goiden Rod) <br /> REVISED 11/17/2003 <br />