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Ate <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# =SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> Rafael Viramontes CHECK If BILLING ADDRESS <br /> FACILITY NAME RogetNiramontes Property <br /> SITE ADDRESS 6425 E. Dougherty Rd. Acampo 95220 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 7481 E. Highway 12 <br /> Street Nember -,reet Name <br /> CITY STATE ZIP <br /> Lodi CA 95240 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 483-0847 017-140-47 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Rocco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> C'TY Lodi STATE CA LP 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 ENvIRoNMENrA1 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 wo;h to perfbqnFd7Nill be/done in accordance with all S AQUIN <br /> COUNTY Ordinance Codes,Standards,STA FEDERAL laws. f <br /> APPLICANT'S SIGNATURE: DATE: 1 CJD�1Zo 11 <br /> PROPERTY/BUSINESs OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT is not the BILLING PAR proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 environmen(�Usi assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and atI[}Sq �tigTc it is <br /> provided to me or my representative. R r.`1I�M <br /> TYPEOF SERVICE REQUESTED: Review Surface & Subsurface Contamination /Rfeporrt,,�,., / <br /> COMMEMS: ( �f�/Vc�-""`-'- lS( Ti-1- Ar— (a'(g `y JOAQUI OI� <br /> poli I AIW NCOUN <br /> M�IITil fAl MENS <br /> ACCEPTED BY: EMPLOYEE#: DATE: % -Ed- ) -7 <br /> ASSIGNED TO: EMPLOYEE#: DATE: ?- J 1 _ J —7 <br /> Date Service Completed (if already completed): SERVICE CODE: !-- 2 P I E: z(FC) <br /> Fee Amount: ex) Amount Pa' 3� b Payment Date 3/ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />