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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK if BILLING ADDRESS <br />SERVICE REQUEST # <br />BUSINESS NAME <br />So.o a2 iiz <br />OWNER/ OPERATOR <br />EXT. <br />Justin Parker <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Parker Property <br />369-0375 <br />SITE ADDRESS 25280 <br />N. <br />Graham Rd. <br />Acampo <br />95220 <br />StreetNumber <br />Direction <br />Street Name <br />STATE CA <br />Ci <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) same <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 530) 517-3158 <br />007-250-40 <br />PHONE #2 EXT • <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />Abby Racco <br />BUSINESS NAME <br />PHONE # <br />EXT. <br />Live Oak GeoEnvironmental <br />209 <br />369-0375 <br />HOME Or MAILING ADDRESS <br />FAX # <br />407 W. Oak St. <br />( ) <br />CITY Lodi <br />STATE CA <br />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 LndFE 1�ws. <br />APPLICANT'S SIGNATURE: G 4 DATE: <br />PROPERTY / BUSINESS OWNER LJ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 SCSI itrate Loading Study :"-< <br />COMMENTS: RECEIVE <br />MAR 0 7 2022 <br />MAR 0 7 2022 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />HF WRONMENTAL PERMIT/SERVICES <br />ACCEPTED BY: � ti EMPLOYEE M fv� DATE: <br />ASSIGNED TO: 77 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 15-23 P / E:Z&O?- <br />Fee Amount: �6 Amount Paid �� Payment Date /LZ <br />Payment Type Invoice # Check # I W �- Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />