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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />IS12, ocxSt I—+ <br />OWNER/ OPERATOR <br />K. Grewal BILLING ADDRESS x❑ <br />Ranjit & Nimaljit Kaler and Tarlochan S. <br />Grewal & Gurbux <br />FACILITY NAME Kaler/Grewal Property <br />SITE ADDRESS 15550 <br />W. <br />Grant Line Rd. <br />I <br />( ) <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) 9740 <br />Ellsmere Way <br />Street Number <br />Street Name <br />CITY Elk Grove <br />STATE CA ZIP 95757 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 408) 410-3014 <br />209-190-08 <br />PHONE #Z EXT. <br />BOS DISTRICT <br />LOCATION�CifODE <br />Cl <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Abby Racco <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />Live Oak Geo Environmental <br />209 369-0375 <br />HOME or MAILING ADDRESS <br />FAx # <br />407 W. Oak St. <br />( ) <br />cITY Lodi <br />STATE CA ZIP 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 d FEDERAL laws. <br />APPLICANT'S SIGNATURE: / DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT [eD+Jit/L-TFt,1- <br />IfAPPLICANT 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 />APR 0 7 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: ����/� EMPLOYEE #: DATE: ?� <br />ASSIGNED TO: AS <br />EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P / E: a4, 03 <br />Fee Amount: 4 ] OL(Amount Paid b — Payment Date Z Z <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />