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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 /> Ron McManis CHECK If BILLING ADDRESS <br /> FACILITY NAME North Forty Property <br /> SITE ADDRESS 19750 N. Lower Sacramento Rd. Acampo T95220 <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 18700 E. River Rd. <br /> Street Number Street Name <br /> CITY Ripon STATE CA ZIP 95366 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 649-6821 013-180-50, -51, -52, -53 P4_ _ (,/ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. (209 )369-0377 <br /> CITY Lodi STATE CA Z'P 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 also certify that I have prepared this a lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,St n ards, STAT and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: v'� -- DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMFNTAI.HEALTH DEPARTMENT as soon as it is available and at the sa time it iS <br /> provided to me or my representative. EN <br /> TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report CE, <br /> COMMENTS: -'//-7 M <br /> AR 1 3 <br /> &5&7*aJia� 1!1 H NT`i <br /> O,DtN COD <br /> sp EN 1HD PAR-TMWNX <br /> Dti <br /> ACCEPTED BY: G j 11G--� EMPLOYEE#: DATE: <br /> ASSIGNED TO: �SL��(6V EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: 2� j PIE: �0 3 <br /> Fee Amount: ��v Amount Paid 71%,�(� d C Payment� Date r :� �S <br /> Payment Type Invoice# Check# l 3 a- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />