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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />SQ o01,371-4, <br />OWNER / OPERATOR X Camillo Leventini CHECK if BILLING ADDRESS <br />FACILITY NAME Leventini / Leventini / Shoup /Alberti / Saco Property <br />SITE ADDRESS8458 & 8200 <br />Street Number <br />E. <br />Direction <br />Jahant Rd. & 23110 N. Dustin Rd. <br />Street Name <br />Acampo <br />City <br />95220 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( 209) 484-6901 <br />APN # 007-050-13, -47, <br />portion of -46 <br />LAND USE APPLICATION # <br />PA-2000115 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Abby Racco CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE <br />Live Oak GeoEnvironmental <br /># <br />(209 )369-0375 <br />EXT. <br />HOME or MAILING ADDRESS <br />407 W. Oak St. <br />FAX # <br />( ) <br />CITY Lodi STATE ZIP CA 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: AXe , DATE: 4-572 1/2- <br /> <br />PROPERTY! BUSINESS OWNER El OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENTI:i Co s,- <br /> <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 sameMe it is <br />provided to me or my representative. PAY An <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study RECEivLu <br />COMMENTS: s( 2 2E MAY '1 1 <br />SAN JOAQUIN COUNTY <br />' --- ac/frO tag/Art <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY:-kc.4v- A 014 EMPLOYEE #: DATE: 57 i I 7z0 a <br />r ASSIGNED TO: \r l 0_ EMPLOYEE #: 1576-,-,. ,i- , , DATE: h <br />Date Service Completed (if already completed): SERVICE CODE: 1:-....; -1,3 I E: <br />Fee Amount: (a 0 a Amount Paid 0 Payment Date (// 2,/ <br />Payment Type p Invoice # Check # 3 t y Received By:),4ll <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)