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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />❑ <br />SERVICE REQUEST # <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />OWNER /OPERATOR <br />El <br />Fernando Cervantes <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Cervantes Property <br />369-0375 <br />SITE ADDRESS 2224 <br />N. <br />I <br />Beyer Ln. <br />I <br />P I E: <br />Stockton <br />95215 <br />Street Number <br />Direction <br />Street Name <br />STATE CA <br />CibL <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Received By: <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( ZOy ) 41( 7 y/ <br />101-022-58 <br />PHONE #Z EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Review Soil Suitability/Nitrate Loading Study <br />❑ <br />Abby Racco <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # <br />EXT. <br />Live Oak GeoEnvironmental <br />209 <br />369-0375 <br />HOME or MAILING ADDRESS <br />SERVICE CODE: <br />FAX# <br />P I E: <br />407 W. Oak St. <br />( ) <br />Amount Paid d _ <br />CITY Lodi <br />STATE CA <br />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, STATE --- laws. <br />APPLICANT'S SIGNATURE: --- DATE:iM—� 7 <br />PROPERTY / BUSINESS OWNER❑ 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 />nment <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or enviroa6AYt <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tREEVOtb <br />provided to me or my representative. ALJ <br />TYPE OF SERVICE REQUESTED: <br />Review Soil Suitability/Nitrate Loading Study <br />JUN 2 / 2022 <br />COMMENTS: <br />SAN JOAQUIN COUN <br />ENVIRONMENTAL <br />HEALTH DEPARTMEN <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <br />Amount Paid d _ <br />Payment Date <br />Payment Typevl <br />Invoice # <br />k # `� J �p Z� <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />