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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVJU RE_QVEST# <br /> OWNER/OPERATOR Mark Ackerman CHECK if BILLING ADDRESS <br /> FACILITY NAME Ackerman Property <br /> SITE ADDRESS 5861 W. Kile Rd. Lodi 95242 <br /> Street NumberFDir . I Street Name city 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 /> (209) 210-7399 001-280-10 <br /> PHONE#2 EXT. BOS DISTRICT L LOCATION CODE <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. ( ) <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 work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST anFE laws. <br /> APPLICANT'S SIGNATURE: u�- - DATE:O'S D Z <br /> C" r <br /> PROPERTY/BUSINESS OWNER® OPE TOR/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 t0 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 Pq <br /> COMMENTS: <br /> SqN MAY p2020 <br /> FN/0 4 Q(IIIV <br /> HEAL V/R N411COU V77' <br /> ACCEPTED BY: ! EMPLOYEE#: DATE: S Z . j <br /> ASSIGNED TO: N 2 EMPLOYEE#: DATE: S /La Z4 <br /> Date Service Completed (if already completed): SERVICE CODE: C.23 PIE: 16 <br /> Fee Amount: �0�,' Amount Pai Payment Date 7 <br /> Payment Type Invoice# Check# SS/ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />