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SAN JOAQULN COUNTY ENVIRONMPNTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />SOO <br />OWNER / OPERATOR <br />Monica Sweeny CHECK if BILLING ADDRESS X <br />FACILITY NAME Sweeny Property <br />SITE ADDRESS 31296 <br />Street Number <br />E. <br />Direction <br />Rossier Rd. <br />Street Name <br />Escalon <br />City <br />95320 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) same <br />Street Number Street Name <br />CiTY STATE ZIP <br />PHONE #1 Err. <br />(209) 679-4161 <br />APN tt <br />229-200-08 <br />LAND USE APPLICATION # <br />PHONE #2 Err. <br />( I <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ci Abby Racco CHECK if BILLING ADDRESS <br />BUSINESS NAME Live Oak GeoEnvironmental PHONE # <br />(209 ) 369-0375 <br />Err. <br />HOME or MAILING ADDRESS <br />407 W. Oak St. <br />FAX # <br />( ) <br />CITY Lodi STATE CA ZIP 95240 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sum, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALITI 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 FT4RAL laws. <br />APPLICANT'S SIGNATURE: ' 1,1A,061)&fl G17— DATE: 1 6 1/g I , 21 <br />PROPERTY / BUSINESS OWNER g OPERATOR / MANAGER 0 J OTHER AUTHORIZED AGENT El r-r)1a jefooc Qu.metz <br />If APPLICANT 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 environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tpAYMENTs <br />provided to me or my representative. <br />rt. 11.0.art.,31, wiii new <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability / Nitrate Loading Study <br />COMMENTS: OC1 1 S 2021 <br />SAN JOAQUIN COLN' <br />ENVIRONMENTAL, <br />HEALTH DEPARTME <br />ACCEPTED BY: <br />/11M7-__ <br />EMPLOYEE #: DATE: <br />ASSIGNED TO: <br />V' Go VriZ-Wil EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: C 2..,,,3 , P/ E: D-2 <br />Fee Amount: 7.,bi- q2. Amount Paid C) 2 Payment Date i 6//. it, / <br />. :-- Payment Type \) 1.,e,t.. Invoice # 9:uactri i "? '2,Lo Li (zit -- Received By: 741 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003