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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#i SERVICE REQUEST#I <br /> .544-00 &'f'?9q <br /> OWNER/OPERATOR <br /> Greg Bums CHECK if BILLING ADDRESS <br /> FACILITY NAME Spenker Ranch <br /> SITE ADDRESS 2651 W. Tumer Rd. Lodi 95240 <br /> sveet..7rZip Code DiSft"t Nam <br /> HOME or MAILING ADDRESS (If Different from Site Address) p,0. Box 1406 <br /> Street Number <br /> Street Name <br /> CITY Woodbridae STATE CA zip 95258 <br /> PHONE#1T APN# LAND USE APPLICATION# <br /> (209 )481-6951 T013-050-19 PA-1300070 <br /> 1 PHONE#2 EkT• BOS DISTRICT -�7LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS❑ <br /> BuslNEssNAME Live Oak GeoEnvironmental PHONE# &T. <br /> 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( )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 e I be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE RAL la <br /> APPLICANT'S SIGNATURE: DATE: 3 <br /> PROPERTY/BUS1NES.S OWNER i0 OP / OTuER AUTHORIzED AGENT 0 <br /> IjAPPc tcA/vT is not th NG PARTY proof of authorization to sign is required Title <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 environmen Usite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at time it is <br /> provided to me or my representative. A <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability <br /> I Stud FST F <br /> COMMENTS: It{'II '�" SAN JD �Uli' <br /> jzc,torT PcL/wda�, 3 a"nn'r HF`Nvgo���c 7 <br /> /�. C, E�l�b TtiOF qA t fY <br /> C T <br /> ACCEPTED BY: / 7/I EMPLOYEE M x 7 DATE: / <br /> ASSIGNED TO: �2� 1lie G S &L,-f L EMPLOYEE#: 13-11 <br /> o1 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P l E: -2-6, 1 <br /> Fee Amount S. <br /> 2->C) - Amount Paid �25d DD Payment Date / <br /> Payment Type Invoice# Check# Z 3 r Received BEHD . <br /> REV SED 11/1 SR FORM(Golden Roc) <br /> REVISED 11/17/2003 <br />