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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />Abby Racco <br />REQUEST # <br />BUSINESS NAME <br />C <br />VV11SEEjR�)VICE <br />mDw <br />OWNER/ OPERATOR <br />El <br />James & Angela La Velle / John & AnnaMarie Lara <br />CHECK if BILLING ADDRESS <br />FACILITY NAME La Velle / Lara Property <br />407 W. Oak St. <br />%E to 112619,ee3N 705 <br />( ) <br />Koster Rd • <br />Tracy <br />95304I <br />Direo�tlon <br />Street Name <br />��t <br />Zip e <br />HOME or MAILING ADDRESS (If Different from Site Address) 475 <br />W. Blewett Rd. <br />c/o Carl Navarra Street Number <br />Street Name <br />CITY STATE <br />ZIP <br />Tracy CA <br />95304 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209) 471-5757 <br />255-100-26, -35, & -36 <br />PA -2100156 <br />PHONE #2 EXT. <br />l ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Abby Racco <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />Live Oak Geo Environmental <br />209 369-0375 <br />HOME or MAILING ADDRESS <br />FAX# <br />407 W. Oak St. <br />( ) <br />CITY Lodi <br />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 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 EDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 1(- -2- 1 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Co #'J5 uCT i <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 <br />COMMENTS: <br />Vs <br />1 <br />SAN✓O §®�% <br />yF �NT u,�Y <br />ACCEPTED BY: /-V5 Z— EMPLOYEE #: DATE: I I// d - <br />ASSIGNED TO: EMPLOYEE #: DATE: I I / J S ,? <br />Date Service Completed (if already Completed): SERVICE CODE: P 1 E: a 6 <br />Fee Amount: J Amount Paid bo. Payment Date l <br />Payment Type Invoice # Check # 1863 Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />