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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> RESIDENCE <br /> OWNER/OPERATOR <br /> JOANN SHIPHERD CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> S116375SS E MILGE0 ROAD RIPON 9566 <br /> Street Number Direction Street Name Ci 1 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 168 HILLTOP CRESCENT <br /> Street Number Street Name <br /> CIT' WALNUT CREEK STATtA zip 94597 <br /> PHONE#') EXT. APN# LAND USE APPLICATION# <br /> (925)935-9441 261-220-11 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR TAMARA WOODS CHECK if BILLING ADDRESS <br /> BUSINESS NAME P � EXT. <br /> TERRACON CONSULTANTS INC. n 367-3701 <br /> HOME orMAIUNGADDRESS 902 INDUSTRIAL WAY Fax# <br /> l ) <br /> CITY LODI STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMI-N I'Al. HEALTH DI-TAR'rMENT 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 perfonncd will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATL and FEDLRAL laws. <br /> APPLICANT'S SIGNATURE: Woods, Tamara D,91,-wds Tab,�M,,a"' 09-22-2020 <br /> DN -W000s Tenwra K DATE: <br /> au=General U-' V <br /> _75 mara.-1A s4'— <br /> lerrecon ca' <br /> PROPERTY/BuSINESS OWNER❑ OPERATOR/NfV4-69R°E+1611 31 1�T`�THER AUTHORIZED A(:ENTp CONSULTANT <br /> /I APPLICANT'is not the B/LL IA'G PAR]'),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 CoL NTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at 1h6sslame time it is <br /> provided to me or my representative. / A Y <br /> TYPE OF SERVICE REQUESTED: SOIL SUITABILITY AND NITRATE LOADING STUDY REVIEW F/ <br /> COMMENTS: <br /> sAN�o P�9 ?420 <br /> �J IR NMRCO�N�Y <br /> EPgRTFNT <br /> ACCEPTED BY: y- � EMPLOYEE#: DATE: a p � <br /> ASSIGNED TO: /� EMPLOYEE#: DATE: y al C 0 <br /> Date Service Completed (if already completed): SERVICE CODE: Sa3 P/E: dl- <br /> Amount <br /> c Amount Pai SDS OD Payment Date <br /> Fee Amount: :` Z <br /> Payment Type _ Invoice# Check# ' �S Recel ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />