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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5Roog (31 IV <br /> OWNER/OPERATOR <br /> Eric Lopes CHECK If BILLING ADDRESS <br /> FACILITY NAME Lopes Property �j10— �, 22Jfl <br /> SITE ADDRESS 16520 W. Von Sosten Rd. Tracy 95304 <br /> Street Number Direction Street Name I 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. APN# LAND USE APPLICATION# <br /> (510) 691-2210 209-380-52 <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 GeoEnvironmental 209 369-0375 <br /> HOME Or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE CA z'P 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 wor to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STCE and FEDERAL law <br /> APPLICANT'S SIGNATURE: �� DATE: Z Z' <br /> PROPERTY/BUSINESS OWNER❑ OPERAT R/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proo f 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. ww <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study r <br /> COMMENTS: <br /> EB? <br /> 8 <br /> y Fti°,,Qo v�N C'o X20 <br /> �CTh NMF UN <br /> ACCEPTED BY: S. s r 1 EMPLOYEE#: DA Tp"�)S-- <br /> ASSIGNED TO: N . A h oAe Ck EMPLOYEE#: DATE: _-�- a s-- a Q <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P I E: (0 <br /> Fee Amount: O Amount Paid Payment Date a� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />