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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 />SERVICEREQUEST # <br />BUSINESS NAME <br />PHONE # EXT. <br />Live Oak GeoEnviron mental <br />OWNER / OPERATOR <br />If BILLING ADDRESS X <br />Doug Torres <br />CHECK <br />FACILITY NAME Torres Property <br />407 W. Oak St. <br />SITE ADDRESS 7942 <br />W. <br />Erb Way <br />STATE CA Z'P 95240 <br />Tracy <br />95304 <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />same <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 510) 289-2417 <br />248-230-09 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT 5 <br />JLOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />❑ <br />Abby Racco <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />Live Oak GeoEnviron mental <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, S=dERE laws. <br />APPLICANT'S SIGNATURE: DATE:r 3 - t 0 - 22 <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT 13 Co'I.JSyL-TiK--r <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 />MqR � VFo <br />,NAi qN y® ?0?? <br />oF"pro �Nry <br />ACCEPTED BY: SQ EMPLOYEE #: DATE: � /O Z�� <br />ASSIGNED TO: j EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: S23 P 1 E:2�o2 <br />Fee Amount: Q�' Amount Pai �Payment Date 0 2Z <br />Payment Type Invoice # Check # I Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />