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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> e3zC)�D 3�1�G91�1� <br /> OWNER/OPERATOR <br /> Rick Marrun CHECK If BILLING ADDRESS 0 <br /> FACILITY NAME Marrun Property <br /> SITE ADDRESS 11851W. Valpico Rd. Tracy 95376 <br /> Street Number Di..".u.i I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 38152 Hastings Ct. <br /> Street Number Street Name <br /> CITY Fremont STATE CA ZIP 94536 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (510) 414-8310 242-050-04 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <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 FAX# <br /> 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,Stan and FEDERAL laws. <br /> APPLICANT'S SIGNATU DATE: /Z OS <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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. Aw <br /> TYPE OF SERVICE REQUESTED: Review Nitrate Loading Study _I #—A <br /> COMMENTS: ,\j l 0� J CLCY S�, �� C1�� lI� <br /> coS u a l ' ` EC <br /> 05 <br /> 2018 <br /> S N�AQUIN COU <br /> MATH EAMENT N1Y <br /> ACCEPTED BY: EMPLOYEE#: (jII rJA S DATE:/ Z 2cv <br /> ASSIGNED TO: EMPLOYEE#: 1, / DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: -c7 P 1 E: !�i <br /> Fee Amount: 15 2—+ SZ Amount Paid --3 pc f Payment Date 2 f S J)g <br /> Payment Type Invoice# Check# Received By: <br /> F 85 <br /> EHD 48-02-025 $S4 5 5. -2.40 C-7 (WC/v1 P,© � SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />