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SAN JOAQLIN COCNTN- ENN'IRONNIENTAL HEALTH DEPARTNIF,I <br /> SERVICE REQt: -ST <br /> Type of Business or Property FACILITY ID SERVICE REQUEST <br /> �RQ�ti�"�w2 <br /> OWNER I OPERATOR _,.,... _ <br /> Fabiola Guzman CrrECK if B•LL'NG ADDRESS® <br /> FACILr-YNAME Guzman Property <br /> SITEA:DREss 4011 E. Woodson Rd. <br /> street Nimtxr Direction Street Name Aca m Pi y Zie Cods <br /> 95220 <br /> HOM"e or MkLI!IG ADDRESS (N Different from Site Address) same <br /> Sheet Nwrbe• 5 roe:Nana <br /> CITY STATE zip <br /> P:-ONE#1 Ex' APN# LAND USE APPLICA'ION 9 <br /> (209) 406-6498 005-160-31 <br /> P:wa%E*2 -- _- - - - EXT. 1305 DISTRICT LOCATION C <br /> c ) 9 <br /> CONTRACTOR / SERVICE REQLESTOR <br /> REQUESTOR <br /> Abby Racca CHECK ifBILLINGAnoar=ss❑ <br /> B'JSINESs NAME <br /> Live Oak GeoEnvironmental (209) 369-0375 <br /> HOME or MAILING ADDRESS FAx# <br /> 407 W. Oak St. ) <br /> CITY Lodi STATE CA aP 95240 <br /> BILLLNG ACKNONN-LEDGENIFNT: I, the undersigned propert) or business owner, operator or authorized agent of same, <br /> acknov,lcdgc that all site and•or project specific ENv1RONmFNTaL HEALTH DFPARTMF.NT hourly charges awxiatcd 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 JOAQtm: <br /> CO NIN ordinance Codes,Standards,SrATL•'and FL,m-KAL laws. <br /> APPI.ICAN�'T'S SIGNATURE: . i� _ D:�T F.: <br /> � <br /> PRt�PFRTY;Husmyss Ow--ER13 OPERATOR l jTA\q(:FR ❑ ()TIFF.R AL I HURILGDAGLN'I <br /> If.APPLIC.4\7 is not the B,r_L'.`:G PAaRI77.proof of authorisation to sign is required Title <br /> AI,THORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br /> abo�e site address, hereby authoruc the rcl,:�e of any and all results, geotechnical data and'or environmental/site assessment <br /> information to the SAN JOAQLX%COLN-1Y E\-viRON4IENTat,HEALTH DEPART-%!FNT as soon as it is available and at the same tit P4 <br /> provided to me or my representative. <br /> TYPE OF SERVICEREauESTED: Review Soil Suitability/Nitrate Loading Study /VF 1 <br /> CoMM:h's: <br /> sqNkAis� 1 <br /> �ii rG —9 (.t'K LT—� �zt t Cl�1 "-'� S'S/1!L f ^mor'¢—SNFA jN� ?023 <br /> pM COO <br /> / A <br /> q T MENT <br /> ACCEPTED BY: EMPLOYEE DATE. S�2 Z3 <br /> ASSTGNEC)TO: C EMPLOYEE#: DATE: <br /> Date service Completed (if already completed): SERVICE CODE: 5�fes?) P i E: Q Z <br /> Fee Amount: � Amount Paid 2, . loo Payment Date S/ <br /> Payment Type Ckedi Invoice# Cha*At Rece By: <br /> i <br /> E-.0:&G2-L25 SR FORM(GolCen Roe) <br /> RE':'ISE.:,1111712003 <br />