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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sk 5-T� ;�- <br /> OWNER/OPERATOR <br /> Brent & Janelle Holfman CHECK if BILLING ADDRESS X❑ <br /> FACILITY NAME Holfman Property <br /> SITE ADDRESS 7272 1 E. Lathrop Rd. Manteca 95336 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 12191 E. Louise Ave. <br /> Street Number Street Name <br /> CITY Manteca STATE CA ZIP 95336 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 479-5410 218-050-01 <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# ExT. <br /> Live Oak Geo Environmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. <br /> ( ) <br /> CITY Lodi 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,STATE and FJJERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: q V -2-0-Z--2— <br /> PROPERTY/BUSINESS OWNER❑ JILLING <br /> ERATOR/MANAG ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not PARTY,pr of 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 St YME <br /> COMMENTS: LVED SEP 14 2022 <br /> SEP 14 2022 ENVIRONMENTAL HEALTH <br /> SAN JOAQUIN PERMIT/SERVICES <br /> ENVIRON COUNTY <br /> HEALTH DEpgRT'L <br /> ACCEPTED BY: Z—L EMPLOYEE#: DATE: <br /> ASSIGNED TO: �' EMPLOYEE#: DATE: 0-1// <br /> Date Service Completed (if already completed): SERVICE CODE: S 3 P 1 E: a 6v aZ <br /> Amount: a LI Amount Paid Payment Date l 2-2— <br /> Fee Payment Type / <br /> & Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />