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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID N SERVICE REQUEST# <br /> _j I <br /> �2.rb(p S3f <br /> OWNER I OPERATOR <br /> Susan Balogh/Jean Kent CHECK if BILLING ADORE55E] <br /> FAGLrrYNAME Balogh/Kent Property <br /> SITE ADDRESS 19625 N. Southworth Rd. Lodi s 2-40 <br /> Street Hamper <br /> Cadp <br /> HOME W MAILING ADDRESS (If Different from Site Address) P.O. Box 181 / 141 <br /> Strwl Nu.: <br /> cm Wallace STATE CA ZIP 95254 <br /> RHONE#I fir' APN# LAND USE APPLICATION# <br /> (209 )763-5253 023-260-01 N/A <br /> PHONE#2 Ekt' 130S DISTRICT LOCATIONCODE <br /> ( )763-5590 --o" <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS❑ <br /> BUaINEss NAME PHONE Live Oak GeoEnvironmental (209 �* <br /> 209)369-0375 <br /> HOME Of MAILING ADDRESS 407 W. Oak St. FAX# <br /> l ) <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site and/or project specific ENVMONMENTAL HEALTH DEPARTNIENT 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordirtonee Codes,Stnn,A�A STATE e d FEDMZA.L Iaws. 1' ✓ <br /> APPLICANT'S SIGNATOR \m ✓M�IYAI_,-M-N�__.IID�JNYfJo DATE: GV• �'�'D `lpi3 <br /> PROPERTY/BOstNEss OWNER OPERATOR/NIANAGER AuTEoRIZFD AGENT 13 <br /> If.-I PPLIC4NT is no!the BIL 1,MG,P.IR7'1'.proof of authorization to sign L required Tirt e <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 environmentaltsite assessment <br /> infomlatiem to the SAN JOAQU X COUNTY ENVIRONhENTAL 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 PAYMENT <br /> CortENre: RECEIVETr- <br /> �D G1 fi.Lo 7/g//I(- 7/eY/�y� <br /> NOV E 0 2013 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M 'lam 7L1 DATE: I t ap l T <br /> Aaax1NED TO: A,'1/� EMPLOYEE#: 5-7 Ly- y DATE: J <br /> Date Service ComOf already completed): SERVICECODE: 5 2 Z- IPIE: <br /> Fee Amount 2,'-0 --� Amount Paid -15b -- Payment Date 1,1 20 L-5 <br /> Payment TypeC'Lj Involae# Check# ZJD%2j Received By. <br /> EHD 48-02025 SR FORM(Golden Rod) <br /> REVISED 11/172003 <br />