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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Rikki & Brett McIntosh CHECK If BILLING ADDRESS X <br /> FACILITY NAME McIntosh Property <br /> SITE ADDRESS 2381 1 S. Jack Tone Rd. Ripon 95366 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1333 W. 4th St. <br /> Street Number Street Name <br /> CITY Ripon STATE CA ZIP 95366 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 851-5022 228-170-34 <br /> PHONE#2 EXT. BOS DISTRICT1 LOCATION CODE <br /> ( ) 9 <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 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,STAT and FEDERAL lav <br /> APPLICANT'S SIGNATURE: DATE: Jy Lc7 <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, 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. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Nitrate Loading Study INV <br /> COMMENTS: 16.1 ED <br /> sgnlJ It 0 2 2020 <br /> N EN oRONM CO <br /> EAITy DEp � <br /> ACCEPTED BY: �- EMPLOYEE#: DATE: J o? av,2O <br /> ASSIGNED TO: EMPLOYEE#: DATE: 7 <br /> 10? <br /> apd D <br /> Date Service Completed (if already completed): SERVICE CODE: S a P 1 E:dgo..? <br /> Fee Amount: �, O Amount Paid (00'R r Payment Date OZ.S <br /> Payment Type Invoice# Check# :2 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />