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...,4._., _____ , __ . ----·---SERVICE REQUEST --1ype of Business or Property --FACILITY ID# SERVICE REQUEST # s;Rooi011u OWNER / OPERA TOR ~ CHECK If BILLING ADDRESS IEI FAciuTYNAME Rivermaid Trading Co. SITE ADDRESS 6550 Street Number Cl 95240 Zi Code HOME or MAILING ADDRESS (If Di c/o Ton Construction Street Numb r P.O. Box 2701 Street N m CiTY Lodi PHONE #1 ( 209) 666 5484 PHONE #2 ( ) E . APN# 049-120-04 STAT CA ZIP 95241 LAND U E APPLICATION # PA 2100295 BOS DISTRICT L/ CONTRACTOR I SERVICE REQUESTOR REQUESTOR R Abby acco CHECK 'f BILLING AODRE_SS □ BUSINESS NAME . . PHONE# ExT. Live Oak Ge0Env1ronmental < 209 l 369-0375 HOME or MAILING ADDRESS W O k S FAX# 407 . a t. ( ) CITY Lodi STATE CA ZJP 95240 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same acknowledge that all site and/or project specific ENVIRONMENT AL HEAL TH DEPARTMENT hourly charges associated with this project or a ti· it:y will be billed to me or my business as identified on this form. I also ertify that I ha e prepared this application and that the work to be performed will be done in accordance-.. ith all S JO QUIN Co Ordinance Codes, Standards, STATE and FEDERAL laws. ~~~ APPLICANT'S SIGNATURE: PROP RT / B OWNER□ OPERATOR/ ~AGER 0 DATE: Lf / 1 1 / 2--2------------------OTHER AUTHORIZED AGENT '2J c)7 f'1. y-/-q fU> /"" _____________ ...__ ____ _ If AP PUCA Tis not the BILLING PARTY. proof of authorization to sign is required Tirl e AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the abo e si.te addres , hereby authorize the release of any and all results, geotechnical data and/or en ironmental/site assessment infonnation to the s JOAQU COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is a ailable and.at the same time it is pro ided to me or my representative. ,-,~ ~ TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study COMMENTS: ACCEPTED BY: ~~ L-L-EMPLOYEE#: ASSIGNED TO: ·f / /' __, f t'-111 j( e7 EMPLOYEE#: Date Service Completed (if already completed): SERVICE CODE: ;;-~ 3 Fee Amount: j (:. D g Amount Paid Payment Date Payment Type Invoice# SR FORM lGo\den Rod)