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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />5ROOS5 1 a 5 <br />OWNER / OPERATOR <br />Jorge Sandoval CHECK if BILLING ADDRESS x <br />FACILITY NAME Sandoval Property <br />SITE ADDRESS 25130 <br />Street Number <br />N. <br />Direction <br />Pearl 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 <br />same <br />Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( 209) 210-7367 <br />APN # <br />007-250-18 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />o0 4 <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 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 407 W. Oak St. <br />FAX # <br />( ) <br />CITY Lodi STATE c A 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: <br />PROPERTY / BUSINESS OWNER El OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 0 <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 saw time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study WCO- ;Cr fre COMMENTS: isow 4p# 0 <br />8 ,?ecli ic-Pe 4922 <br />ii 424% -414 %Iv " co <br />771DEp4147-44v4 <br />ctitr <br />ACCEPTED BY: .5-e f 4 NO (I I EMPLOYEE #: q 4 g DATE: 4 igic:4) <br />ASSIGNED TO: rarICiScO kuiZ r EMPLOYEE #: elq 3g DATE: 4// ,.. <br />Date Service Completed (if already completed): <br />i - <br />SERVICE CODE: S c 5 4) 3 P I E: ,•:) 6 (:),, <br />Fee Amount: SIT „1-- 301f:, tip Amount pa Payment Date 4*7_2___ <br />Payment Type A ,,-t- Invoice # Check # 1 if] 7-1.,,,_._,3 Received By:der — <br /> <br />DATE: <br /> <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003