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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />-200Cr))9 <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />Berton Costamanga CHECK if BILLING ADDRESS x <br />FACILITY NAME Delta Packing <br />SITE ADDRESS 6021 <br />Street Number <br />E. <br />Direction <br />Kettleman Ln. <br />Street Name <br />Lodi <br />City <br />95240 <br />Zip 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. <br />( 209) 321-4538 <br />APN # <br />049-230-11 <br />LAND USE APPLICATION # <br />PA-1100129 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LI LOCATION CODE <br />C3C/ <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Abby Racco CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE <br />Live Oak GeoEnvironmental <br /># <br />(209 <br />EXT. <br />)369-0375 <br />HOME or MAILING ADDRESS <br />407 W. Oak St. <br />FAX # <br />( ) <br />crry Lodi STATE CA ZIP 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, STAT nd FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: •-t- I 2" I <br /> <br />PROPERTY! BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT E21 Colu.su L-T"0-31- <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 PAI yjoAk <br />COMMENTS: ftCP"r1EAfr <br />../tit <br />0 / <br />8/1N JOA 202/ <br />h, 404 QU/N r, <br />ACCEPTED BY: _.---- Z Z EMPLOYEE #: DATE: 7/ <br />ASSIGNED TO: TO: b A EMPLOYEE #: DATE: 1///0? i <br />Date Service Completed (if already completed): SERVICE CODE: c.? 3 P I E: <br />Fee Amount: 4-- 00 Amount Pa 66g: 6---D Payment Date ' <br />/ <br />Payment Type dv_.e , Invoice # Check # 1 62__Ve,D Received By: ?/#7)----- <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003