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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICREQUEST# <br /> --- L5�oovyoi <br /> OWNER/OPERATOR <br /> Ernest & Pam Holguin CHECK if BILLING ADDRESS <br /> FACILITY NAME Holguin Property <br /> SITE ADDRESS 9100 N. Jonathon Ct. Stockton 95212 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) FP.O. Box 691225 <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95269 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 298-3823 085-580-07 <br /> PHONE#2 EXT. BOS DISTRICT I LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS O <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak Geo Environmental 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: 1, 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, STA E an EDERAL laws. <br /> APPLICANT'S SIGNATURR�E DATE: v U <br /> PROPERTY/BUSINESS OWNER IpL PERAT /MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLIN PARTY proof o uthorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFO TION: 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 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. A' <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Nitrate Loading Study 'RZ f, �r <br /> COMMENTS: D <br /> OCj 3� 2020 <br /> M NV/RoNtN COON <br /> FACTy DE AR�� <br /> ACCEPTED BY: EMPLOYEE#: DATE: IO 3J apa'� <br /> ASSIGNED TO: j EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S oZ P i E: <br /> Fee Amount: J Amount Paid Payment Date �ro 30 �j I <br /> a <br /> Payment Type Invoice# Check# � Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />