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SAN JOAQI 4D COUNTY ENVIRONMENTAL HEALTH TMENT <br />CFRVTC F, REOUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />CHECK <br />DATE: "(1? -31 1 <br />EMPLOYEE #: Z L, � <br />PHONE # EXT. <br />Vacant <br />Date Service Completed (f already completed): <br />( 209 ) 467-1006 <br />HOME or MAILING ADDRESSFAX# <br />837 Shaw Road <br />E] <br />OWNER / OPERATOR Levand Family Trust <br />CHECK if BILLING ADDRESS <br />FACILm NAME Levand Property <br />Payment Type / <br />SITE ADDRESS 47 <br />Eas <br />Eleventh Street <br />Tracy <br />95376 <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 24692 <br />Sand Wedge Lane <br />Street Number <br />Street Name <br />CIN <br />STATE ZIP 91355 <br />CA <br />Valencia <br />EXT. <br />PHONE #1 <br />APN # <br />LAND USE APPLICATION # <br />( 661 ) 904-2133 <br />233-369-14 <br />EXT. <br />PHONE 12 <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />U > <br />1 u <br />rnAT'T'DAd-1IP"I? hCTiT2V1('H'. RPA111N:NIt;K <br />Y u'v _ v+- v <br />if BILLING ADDRESS <br />REQUESTOR Robert Marty�v <br />CHECK <br />DATE: "(1? -31 1 <br />EMPLOYEE #: Z L, � <br />PHONE # EXT. <br />BUSINESS NAME Advanced GeoEnviron mental, Inc. <br />Date Service Completed (f already completed): <br />( 209 ) 467-1006 <br />HOME or MAILING ADDRESSFAX# <br />837 Shaw Road <br />( 209 )467-1118 <br />CITY Stockton <br />STATE CA ZIP 95215 <br />BILLING ACKNOWLEDGEMENT: 1. the undersigned property or business owner, operawr Ut 4"&"VA —..r"- .. <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEAuni DEPARTMEN'r 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:atG L�( O/�s�� !/ DATE: <br />S� <br />V114, <br />PROPERTY/ BUsoNESSOwNER® OPERATOR/MANAGER ❑ OTHER AUfI{ORIZF.DAGENT <br />❑ <br />Il'APPLICA.VT 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 HEAL: TH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />"� <br />TYPE OF SERVICE REQUESTED: �j �/v lL Jzo"LO('�-J c <br />COMMENTS: A EDF 1tt . ?GD <br />+113V fvr hero ct�(it�b '� SEP 2 3 2013 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />ACCEPTED BY: y1 1 <br />V <br />/ (�� <br />EMPLOYEE #: 2A - Ly <br />DATE: "(1? -31 1 <br />EMPLOYEE #: Z L, � <br />DATE: <br />ASSIGNED TO: ) �fL-� <br />Date Service Completed (f already completed): <br />SERVICE CODE: � 2j L -i' <br />P I E: <br />Z 3cc) —4 <br />Fee Amount: "7,'� <br />— --- -- Amount Paid 7 -- -- Payment Date <br />/01 I <br />Payment Type / <br />Invoice # <br />Check # '? <br />R eived By: <br />/ <br />Ruav,-4 <br />t�7� <br />VI a �� <br />D�11 �lt FORM (Golden Rod) <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />