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SAN JOAQUIN COUNTY EN'VIRON1VIENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Single family dwelling <br />FACILITY ID # SERVICE REQUEST # s(2 DD?,'--- i LA 2- <br />OWNER / OPERATOR <br />do Baez Geotechnical Group, Inc. CHECK if BILLING ADDRESS. <br />FACILITY NAME 285 S Austin Road <br />SITE ADDRESS 285 <br />Street Number <br />S <br />Direction <br />Austin <br />Street Name <br />Manteca <br />City <br />95336 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) PO Box 296 <br />Street Number Street Name <br />CITY STATE CA ZIP Oakdale 95361 <br />PHONE #1 Err. <br />( ) <br />APN # <br />228-020-480 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT 2 LOCATION CODE <br />toolt.ece., <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Acorn Onsite, Inc. CHECK if BILLING ADDRESS <br />BUSINESS NAME Acorn Onsite, Inc. <br />PHONE # <br />( 925) 447-5200 <br />Err. <br />HOME or MAILING ADDRESS 2288 Buena Vista Avenue <br />FAx# <br />( 925 )447-0919 <br />CITY Livermore STATE CA ZIP 94550 <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, ST ATE and laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER!!! OPERATOR / MANAGER 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 PAfl " ENT provided to me or my representative. <br />‘ RIC‘.01G II V IC <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: APR 13 2( <br />Review of engineer prepared OWTS Plan c''''-'' I `^-1 '4'kj')1 e 1 'Y' 11 I'V‘ I i - $SAN JOAQUIN CO <br />ENVIRONMEN <br />HEALTH DEPART <br />ACCEPTED BY:.,-•--- ---/,._ 4/ Z EMPLOYEE #: DATE: Ili/VR .7 <br />ASSIGNED TO: A ci EMPLOYEE #: DATE: 14/10 A <br />Date Service Completed (if already completed): SERVICE CODE: S 0 <br />Payment Date <br />Received <br />2417/5/2.47 <br />P/E: L/ £O I <br />2 2_ Fee Amount: 430 Li Amount Paid 6 k-/ — <br />Payment Typ 414"..\._ Invoice # Check # By: /4,..i <br />DATE: z2_ <br />22 <br />UNTY <br />AL <br />ENT <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003