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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR <br /> Cliff Lenzi CHECK If BILLING ADDRESS El <br /> FACILITY NAME Lenzi Lantz Development CCG <br /> SITE ADDRESS 3222 E. Collier Rd. <br /> Acampo 95220 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 847 Cluff Ave., Ste. B-1 <br /> Street Number Street Name <br /> CITY Lodi STATE CA ZIP 95240 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 643-3215 005-146-07 PA-1700166 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) C <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR K; <br /> Abby Ra KA 1 K;E —(%-.I CHECK If BILLING ADDRESS <br /> BUSINESS NAME /� I r `,� 1 PHONE# ��p�r �� EXT. <br /> IVP Oak (�eoEAv4QAA;Ewtal �tt lJ� 1�4�1' `"� 209 Mgt <br /> HOME or MAILING ADDRESS FAX# <br /> 407141 -Oak St. Q , d (3 x Z l Jt, (209 )3&9r-� 73Y-,>-7z-3 <br /> CITY Lodi STATE CA zlP q� Gds.Z Y I <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. <br /> APPLICANT'S SIGNATURE <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 9 <br /> IfAPPL/CANT 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 availnd at the same time it is <br /> provided to me or my representative. 14Y <br /> TYPE OF SERVICE REQUESTED: Review Nitrate Loading Study <br /> COMMENTS: <br /> EP 12 2018 <br /> JOAQUI <br /> HrpPCCU <br /> 7YryEge � <br /> ACCEPTED BY: S S EMPLOYEE#: DATE: q—//—q <br /> —//—q <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed Of already completed): SERVICE CODE: S P 1 E: ��U c/ <br /> Fee Amount: 3 L '-, Amount Pa 3t ,b7\ Payment Date A� <br /> Payment Type GI Invoice# Check# Id' Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />