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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5121���56�a <br /> OWNER/OPERATOR <br /> Antonette Silva CHECK If BILLING ADDRESS <br /> FACILITYNAME Silva Property <br /> SWESI tRESI8447 E, Highway 120 Ripon 95366 <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 18459 E. Highway 120 <br /> Street Number Street Name <br /> CITY Ripon STATE CA ZIP 95366 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (209 ) 988-7977 205-070-39 & -40 PA-1600171 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco 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. (209 )369-0377 <br /> CITY Lodi STATE CA ZIP 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 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, STAIE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Ii DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERAT R/MANAGER ❑ OTHER AUTHORIZED AGENT® GONSVLTFj n+T <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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study <br /> COMMENTS: � �\� Q ` RECl;n,EO <br /> I <br /> �I� 7 AUG 227016 <br /> JOAQ <br /> HES r,,,)u <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNEDTO: 1,0 EMPLOYEEM DATE: <br /> Date Service Completed (if already comp) ted): SERVICECODE: �( PIE: o <br /> Fee Amount:37-1$ Amount Pai ;27B' DDD Payment Date <br /> Payment Type Invoice# Check# /f y Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />