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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> )ee St We,.,-/-/ � � b <br /> OWNER/OPERATOR <br /> Kenneth Hubbard CHECK if BILLING ADDRESS <br /> FACILITY NAME Hubbard Property <br /> SITE ADDRES <br /> 1 448 & 12436 E. Harney Ln. Lodi 95240 <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Differentt frlo/m Site Address) <br /> / Q�t�� ' ' ",'- Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (�Srb) -7(a 6,- aL76o 063-240-25 <br /> PHONE#2 EXT. BOS DISTRICT j ,--][LOCATIOUE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAx# <br /> 407 W. Oak St. <br /> ( ) <br /> c'TY 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 STATE and FED RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: G �Z' ZD Z' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR//MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not t e ILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION ' RELEASE INFORMATION: When applicable, 1, 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. p <br /> TYPE OF SERVICE REQUESTED:- Review Soil Suitability Nitrate Loading Study CC 7- <br /> COMMENTS: /11w r ¢I'//LC.tI f `�'ii`^�l /ice f.� ! /i� � „^�i� - <br /> / S� !i� y(� 2 — / S <br /> IV <br /> Q 1'? ?020 <br /> soli l H4-� �.u��n �,v4AJ Gtr '� �yNFq� �lR�UlN <br /> T ND�p�RT N <br /> T <br /> ACCEPTED BY: �'"� l� L� EMPLOYEE#: DATE: <br /> ASSIGNEDTO: /J� EMPLOYEE#: DATE: /a o70oZb <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P16: <br /> Fee Amount: )"�a� Amount Pai �0y,DD Payment Date 611 <br /> Payment Type �j�A t Invoice# Check# /Q 9�� �� Received By: <br /> o C1 5W,a 0 ej- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />