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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />Q 00 i:'-615•2., <br />OWNER / OPERATOR <br />Jody Kelly CHECK if BILLING ADDRESS X <br />FACILITY NAME Kelly Property <br />SITE ADDRESS 2727 <br />Street Number <br />E. <br />Direction <br />Acampo 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 P.O. Box 430 Street Name <br />CITY STATE ZIP Acampo CA 95220 <br />PHONE #1 EXT. <br />( 707) 689-4043 <br />APN # <br />013-150-09 <br />I LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) II <br />BOS DISTRICT LI LOCATION CODE <br />CI q <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR <br />Abby Racco CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Live Oak GeoEnvironmental PHONE # <br />(209 <br />EXT. <br />)369-0375 <br />HOME or MAILING ADDRESS <br />407 W. Oak St. <br />FAX # <br />( ) <br />CITY 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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: '1-L-2J <br /> <br />PROPERTY! BUSINESS OWNER El OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 121 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />C ONS Ut- <br /> <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 the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability / Nitrate Loading Study PAYMEr . - <br />COMMENTS: RECElvt <br />JUL 0 7 2i. <br />SAN JOAQUIN Co <br />ENVIRONmEN-Ti` HEALTH <br />' <br />DEPART <br />.."---7 ACCEPTED BY: ., //EMPLOYEE #: <br />_ <br />DATE: 7/4 I <br />ASSIGNED TO: F f EMPLOYEE EMPLOYEE #: -0. DATE: 4145p, .-7/7,4 1 <br />Date Service Completed (if already completed): SERVICE CODE: S d a PIE: d6(A;2 <br />Fee Amount: 40y Amount Paid (e06 ,---J Payment Date <br />Payment Type Invoice # Check # Received1009, <br />END 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)