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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE1 REQUEST # <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />OWNER /OPERATOR <br />Jerry Matthews <br />CHECK If BILLING ADDRESS 0 <br />FACILITY NAME Matthews Property <br />HOME or MAILING ADDRESS <br />SITE ADDRESS 19319 <br />E. <br />Oakwood Rd. <br />Stockton <br />95215 <br />Street Number <br />Direction <br />Street Name <br />Z <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />t <br />ri Street Number <br />Street Name <br />CITY kxlvi�— <br />STATE j3p ZIP 99242 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209) 481-8374 <br />185-060-06 <br />PHONE #2 EXT. <br />( )Ly <br />BOS DISTRICT i <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR I <br />REQUESTOR <br />❑ <br />Abby Racco <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />Live Oak GeoEnvironmental <br />ACCEPTED BY: <br />209 369-0375 <br />HOME or MAILING ADDRESS <br />W <br />FAX # <br />407 W. Oak St. <br />( ) <br />CITY Lodi <br />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 FEDERAL laws. M <br />APPLICANT'S SIGNATURE:`��— DATE: <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />/f 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 />above site address, hereby authorize the release of any and all results, geotechnical data and/or environ f s sment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an I e it is <br />provided to me or my representative. RECEIVED <br />TYPE OF SERVICE REQUESTED: <br />Review Soil Suitability/Nitrate Loading Study <br />COMMENTS: <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: 1J <br />W <br />DAT C� <br />ASSIGNED TO: i <br />EMPLOYEE #: �C _ U <br />s <br />DATE: /Z 20 <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Z <br />Pt 1 E: c. <br />Fee Amount: �� <br />Amount Paid — <br />Payment Date <br />3 <br />Payment Type <br />Invoice # <br />Check # O <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />