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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o <br /> OWNER/OPERATOR <br /> Angela Barajas CHECK if BILLING ADDRESS El <br /> FACILITY NAME Barajas Property <br /> SITE ADDRESS 9684 & 96C2 E. Mariposa Rd. Stockton 95215 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 9684 E. Mariposa Rd. <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95215 <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> (209) 649-1622 181-050-11 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) + OCA <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# ExT. <br /> Live Oak Geo Environmental 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: ` CA/ DATE: j - .3 2 <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, 1,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 ffA <br /> Al1E <br /> COMMENTS: � D <br /> MAY a 3 2021 <br /> SAN jOAQUI <br /> N 11�S TTS <br /> ACCEPTED BY: ��Z� 1 EMPLOYEE#: DATE: <- 3 <br /> ASSIGNED TO: AG EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I E. <br /> Fee Amount: 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 />