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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Suzan Nihad CHECK if BILLING ADDRESS <br /> FACILITY NAME Nihad Property <br /> SITE ADDRESS 6599 E. Foppiano Ln. Stockton T9T! 1d, <br /> Street Number Direction Street Name Ci <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 /> l ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. l ) <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,Stand , STATE and FEDERAL laI <br /> APPLICANT'S SIGNATURE: DATE: 12/4/2018 <br /> PROPERTY/BUSINESS OWNER OP /MA GE OTHER AUTHORIZED AGENT❑ <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. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study PAY MEN I <br /> COMMENTS: RECEIVED <br /> DEC 12 2018 <br /> SAN JOAQUIN COUNTY <br /> w� ENVIRONMENTAL <br /> A M IV I h 3/y1h 9 ��I \\!A,'q71 HEALTH DEPARTMENT <br /> ACCEPTED BY: c EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: i L f 7/Z v JS <br /> Date Service Completed (if already Completed): SERVICE CODE: "7` PIE: 2_ v I <br /> Fee Amount: 3 O Amount Paid 30�, a� Payment Date J2 �-Z 1 <br /> Payment Type C Invoice# Check# aptk9 Received B <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />