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SAN JOAQU IN U N TY ENVIRONMENTAL HEALTH DEP 4. RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property _ FACILITY ID # SERVICE REQUEST # <br /> OWNER 1 OPERATOR <br /> Ranjit & Nimaljit Kaler and Tarlochan S . Grewal & Gurbux K . Grewal BILLING ADDRESS <br /> FACILITY NAME Kaler/Grewal Property <br /> SITE ADDRESS 15550 W. Grant Line Rd . Tracy 95304 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address ) 9740 Ellsmere Way <br /> Street Number _ _ _ Street Name <br /> CITY Elk Grove STATE CA ZIP 95757 - <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # .� <br /> ( 408 ) 410 - 3014 209 - 190 -08 <br /> PHONE #Z EXT • R BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK; if BILLING ADDRESS ❑ <br /> BUSINESS NAME � PHONE # Exr. <br /> Live Oak GeoEnvironmental 209 369 = 0375 <br /> HOME or MAILING ADDRESS 407 W . Oak St . FAx # <br /> CITY Lodi STATE CA ZIP 95240 ---- � --- -- - <br /> BILLING ACKNOWLEDGEMENT : L, the undersigned property or business owner, operator or authorized agent of same , <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH D1: PARTMENl ' hourly charges associated NvIth this project <br /> or activity will be billed to me or my business as identified on this form . M*v <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 JO% AQI iIN <br /> COUNTY INTY Ordinance Codes, , lant7dardC , STATE I rd 1" F.DFRAL laws , <br /> APPLICANT ' S SIGNATURE : / /rte DATE : <br /> PROPEKIFY / BUsrNEss OWNER ❑ OPERATOR / MANAGER ❑ OTHER Au'rH01UZEi) AGENT A C pr. )I- Vt"Tft r� T N <br /> 1fAPPLICANT 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 oqgC <br /> above site address , hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAI fri -i 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 !�E <br /> CI <br /> COMMENTS : <br /> APR 0 7 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY : EMPLOYEE # : DATE : <br /> ASSIGNED TO : — -� EMPLOYEE M DATE: ifJ <br /> Date Service Completed ( if already completed) : — SERVICE CODE : / P J E : �' � <br /> Fee Amount : 4 , j TAmount: Paid b --- Payment Date '" <br /> Payment Type Invoice # - Check # i Received By : <br /> EHD 48-02-025 SR FORM ( Golden Rod ) <br /> REVISED 11 / 17/2003 <br />