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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of of Business or Property FACILITY ID #SERVICE REQUEST # <br />'' <br />OWNER / OPERATOR <br />Roberto Sandoval CHECK if BILLING ADDRESS X <br />FACILITY NAME Sandoval Property <br />SITE ADDRESS 4845 <br />Street Number <br />E. <br />Direction <br />Harvest Rd. <br />Street Name <br />Acampo <br />City <br />95220 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />11 28 <br />Street Number <br />Creekside Way <br />Street Name <br />CITY STATE ZIP <br />Galt CA 95632 <br /> <br />PHONE #1 EXT. <br /> <br />. ( 209) 570-1150 <br />APN # <br />017-020-19 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Abby Racco CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE <br />Live Oak GeoEnvironmental <br /># EXT. <br />(209 )369-0375 <br />HOME or MAILING ADDRESS <br />407 W. Oak St. <br />FAX # <br />( ) <br />CITY Lodi STATE CA ZIP <br />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, STATE and FEDERAL laws. <br />n <br />APPLICANT'S SIGNATURE: 0 k i/i DATE: <br /> <br />PROPERTY / BUSINESS OWNER OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT iS not the BILLING 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 environmentaUsite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the saritity it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study <br /> <br />Ir <br />COMMENTS: /7 <br />,iirlf‘t u <br />I <br />- <br />JOk n <br />i-,d <br />-1104 <br />il <br />/4 <br />u <br />v <br />? <br />c <br /> 2019 <br />iipt.,,,,c "w47. <br />ACCEPTED BY: , 1/0 EMPLOYEE #: <br />try j <br />DATE: --7--- Z t <br />ASSIGNED TO' EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 5 2 3 P1 E: z‘..3 0Z_ <br />Fee Amount: 6 0 5 Amount Pa4 4,0g, 6D 1 Payment Date <br />Payment Type V;6„.„..- Invoice # Check # 1.2,20yo g 7 Received By: <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003