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SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL'r- DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S REQ EST# <br /> - L ou U � .� <br /> OWNER/OPERATOR <br /> Eileen Kuil CHECK if BILLING ADDRESS X <br /> FACUm NAME Kuil Property <br /> SR"9,52844, 23050 S Frederick Ave. Ripon 95366 <br /> Stmet Number Dirc-ctlon S at Oma Ca L Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 22844 S. Frederick Ave <br /> _ Stnet Number I Street+Mama <br /> CITY Ripon STATS CA ZJP 95366 <br /> PHONE#1 EtT APN 0 LAND UsE APPUCAT?ON a <br /> (209) 599-4960 228.130 27, 28, 8 -29 <br /> PHONE#2 Ex' Bf DISTRICT _ LF A TION CODE <br /> CONTRACTOR / SERVICE REQ11I.STOR <br /> REQUESTOR <br /> Abby Racco CHECY I BILLING ADDRESS <br /> E ' <br /> BuslNEss NAME Pwi4E It <br /> Live Oak GeoEnvironmental 209 369-03.7 <br /> HOME or MAIUNG ADDRESS FAX# <br /> 407 W. Oak St. <br /> ( r <br /> CITY Lodi STATE CA Z'P 95240 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner operator ­r authorized agent of came, <br /> ac:knowicdge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT h Kuril, ..barges associated with this project <br /> or activit} will be billed to me or my business as identified on this form. <br /> a iso cenif that I have prepared this application and that the work to be performed will be don.-- in accordance with ILII SAN Jt_IAQuIN <br /> HT1' �)ramance <br /> ("odes.Standards,STATE d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: rC6 ( p 1 T ti_ 7 - 1 I - ,- <br /> PROPERTY% BL'SUESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGYvT Ut,7 r%F,?T <br /> H APPLICANT is not the BIL.UNG PARTY.proof of authorization to sign is required rt,i e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable- 1, the owner or operator of the property lucawd at the <br /> abo- �- site address, hereby authorize the release of any and all results, geotechnical daft xid or emironmeiltal'site L"se sSrrment <br /> Information to the SA!, JOAQUIN COI-.' TY ENVIRONMENTAL Iii AI TH DEPARTNII-NT ;1� ,loon as it is 3vatlable :Utd at the same tirne it is <br /> prv%ided h- me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Repott MERIT <br /> COMMENTS: RECEIVE <br /> JUL 11 2022 <br /> SAN JOAQUIN COUNTY <br /> -- ENVIROJJF F-PARTMENT <br /> ACCEPTED BY: — — — EMPLOYEE#: — — //I 7� <br /> l- L-- DATE: f <br /> ASSIGNED TO: ' _ — — EMPLOYEE#' DATE: ]//I J_ ._ <br /> Date Service Completed (if already complstsd): SERVICE CODE: r 3 P I E: <br /> Fee Amount. Amount Paidjl P (,03 <br /> Payment Date <br /> ll Zp Z Z <br /> ��Payment Type Invoice# Check# Z - Received By: <br /> EHD 46-02-025 #� >4 ,f <br /> REVISED 11/172v003 7 e4b- • SR FORM(Golden Rod) <br />