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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> - dW 3361 s <br /> OWNER/OPERATOR <br /> Greg Van Dyk CHECK If BILLING ADDRESS <br /> FACILITY NAME Van Dyk Property <br /> SITE ADDR S <br /> L6290 & 20306 E. River Rd. Ripon 95366 <br /> Street Number Direction Street Name I Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 20306 E. River Rd. <br /> Street Number I Street Name <br /> CITY STATE ZIP <br /> Ripon CA 95366 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 629-1466 245-230-43 & -39 <br /> PHONE#2 EXT. BOS DISTRICT L LOCATION CODE <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. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPE R/ ANAGER ❑ HR 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 YNjE <br /> COMMENTS: �V�D <br /> MAR ?021 <br /> SAN JOAQU! <br /> HSN H O�ARTT� �Y <br /> ACCEPTED BY: ��Z EMPLOYEE#: DATE: 3111 Q70A? <br /> ASSIGNED TO: /V EMPLOYEE#: DATE: -?//I <br /> a / <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: a?(Oa <br /> Fee Amount: ��'O R Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />