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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> oagy�� <br /> OWNER/OPERATOR <br /> Dean & Jody Shibler CHECK if BILLINGADDRESS� <br /> FACILITY NAME Shibler Property <br /> SITE ADDRESS 3592 & 3434 W. Sargent Rd. Lodi T95242 <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1620 Edgewood Dr. <br /> Street Number Street Name <br /> CITY Lodi STATE CA ZIP 95240 <br /> PHnNF 91 EXT. APN# LAND USE APPLICATION# <br /> (209) 810-5100 025-140-08 & -09 <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME Or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE CA z'P 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 prep7dards <br /> application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,S ,STA and F ERA w . <br /> APPLICANT'S SIGNATUDATE: <br /> PROPERTY/BUSINESS OWNERPERAT ANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RINFORMATION: 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 RECEIVED <br /> COMMENTS: OCT 2 5 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: /ob b d/ <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: A 6 O <br /> Fee Amount: , �' Amount Paid M.— Payment Date ` Z'�T <br /> Payment Type0,41 Invoice# Check# V� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />