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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />Se00?3g34/ <br />OWNER! OPERATOR Henry Martin CHECK if BILLING ADDRESS X <br />FACILITY NAME Martin Property <br />SITE ADDRESS 6103 <br />Street Number <br />W. <br />Direction <br />Delta Ave. <br />Street Name <br />Tracy <br />City <br />95304 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) same <br />Street Number Street Name <br />CrrY STATE ZIP <br />PHONE #1 EXT. <br />( 209) 456-7151 <br />APN # <br />213-100-28 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Abby Racco CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE <br />Live Oak GeoEnvironmental <br /># EXT. <br />(209 )369-0375 <br />HOME or MAILING ADDRESS 407 W. Oak St. <br />FAX # <br />( ) <br />CITY Lodi STATE CA ZIP <br />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 aI FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: /0 -1 - 2- 1 <br /> <br />PROPERTY / BUSINESS OWNER!: OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT El CO Ft)50.. <br /> <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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 same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study —ccov,-;7i <br />CO <br />COMMENTS: <br />C.- 1 <br />JUN / 6 1 avt, 4021 <br />/4.117,RatcouA,,, <br />0E -pkWAL ' ' <br />,M470.. <br />ACCEPTED BY: / 1 / <br />/ 1 j (_} <br />EMPLOYEE #: .S(A) DATE: (3' /716/7e] <br />DATE: 7( 6 7 ---z 1 ASSIGNED TO: A /a ar-a_ EMPLOYEE #: A s <br />Date Service Completed (if already completed): SERVICE CODE: 5- ? <br />Payment Date <br />'3 <br />Received <br />042 <br />P/ E: Z401 <br />1 <br />By: gay/ <br />Fee Amount: (0 C) .__. Amount Paid 0 e <br />Payment Type Oack Invoice # Check # 1-1-1-4 <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)