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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -�?gLr <br /> OWNER/OPERATOR <br /> Mary Carroll CHECK If BILLING ADDRESSE] <br /> FACILITY NAME Carroll Property <br /> SITE ADDRESS 12938 N. Paddy Creek Ln. Lodi 95240 <br /> Street Number Direction Street Name Ci Zio 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 /> (209) 452-5965 063-170-05 <br /> PHONE#2 EXT. BOS DISTRICT _7LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 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 /> C'n Lodi STATE CA z'P 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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. uu�� <br /> APPLICANT'S SIGNATURE: DATE: J r d <br /> PROPERTY/BUSINESS OWNER'NJ OPERATOR/14ANAGER ❑ 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 <br /> COMMENTS: ,Qr <br /> H 01 qv/N C ZQ2� <br /> �cTyo p t74fH�Y <br /> EHT <br /> ACCEPTED BY: i ' EMPLOYEE#: DATE: <br /> ASSIGNED TO: Q tt �� EMPLOYEE#: Dn- DATE: /�/ �� . <br /> Date Service Completed (if already completed): SERVICE CODE: Z j P 1 E: <br /> Fee Amount: Amount Pai (1100 UV Payment Date 5 Z <br /> Payment Type Invoice# Check# S` l0 Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />