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..- # <br /> SAN JOAQU-:I.,COUNTY ENVIRONMENTAL HEALTH,_.�r.PARTMENT <br /> E <br /> SERVICE REQUEST <br />� Q <br /> Type of Business or Property FACILITY iD# SERVICE REQUEST# <br /> E� 5►204���4�— <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> MirMr- Jeff Colorrihin!t FACILITY NAME <br /> Lodi FAPft <br /> ;SITE ADDRESS 102 Live Oak Road Lodl 952 <br /> Stree Nm M ireatlo treat Name Ci ZJ Code <br />` HOME or MAILING ADDRESS (If Different from Site Address) <br /> I 11292 North Alpine Road <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> i� Stockton CA 9.9;212 <br /> EIPHONE#1 Err. APN# LAND USE APPLICATION# <br /> i E (209) 608-2025 063-100-19 ������ � <br /> 1 PHONE#2 ExT BOS DISTRICT IF- <br /> REQUESTOR <br /> OCATION CODE <br /> i( ) <br /> ja CONTRACTOR 1 SERVICE REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> I <br /> BUSINESS NAME PHONE# ExT' <br /> HOME or MAILING ADDRESS FAX# <br /> k 209 369-4228 (209)369-4228 <br /> r CITY STATE CA zip <br /> I Lodi 95240 <br /> :111BILLING ACKNOWLEDGEMENT: I, the undersigned prop or b iness o er, operator or authorized agent of some, <br /> acknowledge that all site and/or project specific ENViR TA HEA TH EPARTME T hourly charges associated with this project <br /> j or activity will be billed to me or my business as identif d on is form. <br /> 1 I also certify that I have prepared this application and t t e wo o be p o ed will b done in accordance with all SAN JOAQUTN h <br /> COUNTY Ordinance Codes,Standards,STATE ERALd s. <br /> i <br /> APPLICANT'S SIGNATURE: ATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERA RI MANAGER 13 OTHE UTHORtZ D GENT❑ <br /> I <br /> ij IfAPPLICANT is not the BILLING ARTY proof Of authorization to quired Title / <br /> I AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owne or operator of the property located at the / <br /> above site address, hereby authorize the release of any and all results, geotechnical to and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon it is available and at the same time it is <br /> t provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Soil Suitability and Nitrate L I Study Review <br /> # COMMENTS: REC6 <br /> RU " M <br /> NOV 1 5 2005 <br /> (1t Ac.+ SAN JOA <br /> D QUIN C <br /> I ENVIRON .,Q <br /> M�r1�.er�,� <br /> APPROVED BY: L( ( {Q�' O rexty �rJZ DATE: <br /> I ' ASSIGNED TO: ._. ([Y �Y,.JS EMPLOYEE#: i�y if f DATE: .. `r CS O <br /> f Date Service Completed (If already completed): <br /> SERVICE CODS: S �-f2 P I E: �& p <br /> Fee Amount: Cr p .SAO Amount Paid w! S d Payment D6 <br /> I <br /> Payment Type I .Invoice.# Gheck.# a5 Received By: <br /> EHE 48-01-025 <br /> SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />