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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Z�Q 00�01SzD <br /> OWNER/OPERATOR <br /> Suzan Nihad CHECK If BILLING ADDRESS <br /> FACILITY NAME Nihad Property <br /> SITE ADDRESS 6599 E. Foppiano Ln. Stockton 95212 <br /> Street Number I Direction Street Name CityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) same <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 456-2033 086-410-20 PA-1800174 <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 Geo Environmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / a DATE: 41-2-3-11 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 191 CoNfyCTAT.�'r <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 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. It <br /> TYPE OF SERVICE REQUESTED: Review Nitrate Loading Study JV-r <br /> COMMENTS: . r�� 4P <br /> /\\/J R 2 4 2019 <br /> ENVIRON COUN7j. <br /> EN <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: w/ <br /> ASSIGNED TO: EMPLOYEE#: DATE: Za <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: Z <br /> Fee Amount: �0 g— Amount Paid �D g Payment Date 4/-2* !� <br /> Payment Type ✓ Invoice# Check#,�j9 Gl Zp(� 8' Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />