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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT i J <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Rafael Viramontes CHECK if BILLING ADDRESS <br /> FACILITY NAME Roget/Viramontes Property <br /> SITE ADDRESS 6425 E. Dougherty Rd. <br /> Acampo 95220 <br /> Street Number 01meflon Name city ZIP Code <br /> HOME or MAILING A}DDDRESS (If Different from Site Address) 7481 E. Highway 12 <br /> Pv x t� Svaet Number IName <br /> CITY STATE ZIP <br /> Lodi CA 95240 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 483-0847 017-140-47 PA-1700199 <br /> PHONE 112 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) 06) I 11 C1 q <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ear. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME Or MAILING ADDRESS Fuc# <br /> 407 W. Oak St. <br /> ( ) <br /> CITY Lodi STATE CA 7"P95240 <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 wor S to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,Sr DEEP-A <br /> APPLICANT'S SIGNATURE: J / / DATA:: I o- 11—20 I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> ff APPLICANT is not the BILLING PAR TP 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. tg <br /> Sgs�': 5..., <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study R@ B <br /> COMMENTS: <br /> 1 IV��� ltbl t^ CW SAIVJO 2 2��I <br /> HEACTy ft�pMR �N]Y <br /> ACCEPTED BY: EMPLOYEE M DATE: )Q =s2_ 7 <br /> ASSIGNED TO: EMPLOYEE M DATE: /b — /p,;� _ / 7 <br /> Date Service Completed (if already completed): SERVICE CODE: 15 Z 3 PIE: <br /> Z f <br /> Fee Amount: Amount Paid 4 1 Payment Date I 0 12 11 -7 <br /> Payment Type ✓ Invoice# Check# S431 Received By: L-6 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />