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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />R ORfilOg <br />OWNER! OPERATOR <br />Abel Patino CHECK if BILLING ADDRESS X <br />FACILITY NAME Patino Property <br />SITE ADDRESS 23848 <br />Street Number <br />N. <br />Direction <br />Pearl Rd. <br />Street Name <br />Acampo <br />City <br />95220 <br />Zip 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. <br />(209) 568-8848 <br />APN # <br />007-270-02 <br />LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT Li LOCATION CODE <br />vi <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Abby Racco CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE <br />Live Oak GeoEnvironmental <br /># <br />(209 <br />EXT. <br />)369-0375 <br />HOME or MAILING ADDRESS <br />407 W. Oak St. <br />FAX # <br />( ) <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: „e"--- DATE: / <br />PROPERTY / BUSINESS OWNER Er- OPERATOR / MANAGER 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 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/Nitrate Loading Study <br />COMMENTS: ikC t:ri iii 7. <br />.///,4 I 8 &ivy jo. 20,f,9 <br />6441114UN cr, <br />7.6( 10121/,'„ • , <br />ACCEPTED BY: EMPLOYEE #: C..) /V k7 DATE: //;f <br />ASSIGNED TO: EMPLOYEE #: C'D s/"..-- DATE: rida <br />Date Service Complete (i f alre y completed): SERVICE CODE: c-z73 1E: zie <br />, <br />Fee Amount: gn v Amount Paid (0042. . crD Payment Date <br />Payment Type (kra_ Invoice # Check # •',9 c Received By:--ci),) <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003