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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C4 0 g�-(y OG <br /> OWNER/OPERATOR <br /> Luz Maria Rodriguez CHECK if BILLING ADDRESS <br /> FACILITY NAME Rodriguez Property <br /> -T <br /> SITE ADDRESS 26515 N. Vail Rd. Thornton 95686 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2050 E. 8th St. <br /> Street Number Street Name <br /> CITY Stockton STATE CA zip 95206 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 743-4790 001-040-17 <br /> PHONE#2 EXT. BOS DISTRICT 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 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: <br /> 49L �%,/G e� 1P Z- DATE: <br /> PROPERTY/BUSINESS OWNERP OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT 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 environment /ilte assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and ataAb it is <br /> provided to me or my representative. ///���'''ec T <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Nitrate Loading Study <br /> COMMENTS: -,SAN JO 020 <br /> A <br /> NEq TH O pgRNOUNTy <br /> 4 L <br /> T MENT <br /> ACCEPTED BY: L� EMPLOYEE#: DATE: �J$"loZ o <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: 3 P I E. 6�a <br /> Fee Amount: 46,0F Amount Pal 460 UD Payment Date / /;Z-0 <br /> Payment Type Invoice# Check# !Z� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />