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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 'SO U6-2)0 1 q <br /> OWNER/OPERATOR Anthony Rose CHECK if BILLING ADDRESS <br /> FACILITY NAME Rose Property <br /> SITE ADDRESS 3511 Jamie Ct. Acampo 95220 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) same <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (510) 388-9845 005-330-01 <br /> PHONE#2 EXT. BOS DISTRICT L LOCATION CODE <br /> ( 1 I C <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 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. J <br /> APPLICANT'S SIGNATURE: DATE: /2II <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑�� <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tule <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 <br /> COMMENTS: <br /> DEC 2 8 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: o?la ' ao ab <br /> j <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1-7/5 <br /> I5� av 3� <br /> Date Service Completed (if already Completed): SERVICE CODE: P/E: 0?6C) <br /> Fee Amount: p�,' Amount Paid Payment Date 1 I^ �j 1�0 <br /> Payment Type Invoice# C # j` C/ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />