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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> E - —35('�::) <br /> OWNER/ OPERATOR <br /> Marc Marchini CHECK If BILLING AODRESSE] <br /> FAclUTYNAME A.M. Farms <br /> SITE ADDRESS 9010 W. Howard Rd. Stockton 95206 <br /> Street Number Ell ectlon I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex . APN# LAND USE APPLICATION# <br /> (209 ) 462-1185 189-190-04&-07; 189-160-12&-23 PA, I Too2z <z- <br /> PHONE#2 En. 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 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, <br /> ^/STATE <br /> Eaand FEDERAL laws. <br /> APPLICANT'S SIGNATURE: C / L2A �/ DA'L'E: / aO rJ /Jr <br /> PROPERTY/BUSINESS OWNERgr OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT is not the Bff,bWGPARTP proof of authorization to sign is required Titre <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,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 availab 0 at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study <br /> COMMENTS: FHv'90 7 JO,c <br /> I f I�IIS pF9ly rM�9v<�s(CI� <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: -2_ I23 PIE: 2 Of <br /> Fee Amount: Amount Pa -6 p,ljD Payment Date l Z 1�I. <br /> Payment Type Invoice# Check# ��c��U Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />