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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Emily Maberto CHECK ffBILLING AOOREssX❑ <br /> FAc,."NAME Maberto Property <br /> SITE ADDRESS 7066 S. Mobley Rd. Stockton 95215 <br /> Strvet Number I Dimikm I Street Name COW zip Go" <br /> HOME or MAILING ADDRESS (N Different from Site Address) 2241 N. Union Rd. #112 <br /> Street Number Street Name <br /> CITY STATE LP <br /> Manteca CA 95336 <br /> PHOME#1 ExT. APN# 187-070-15 LAND USE APPLICATION# <br /> (209) 825-3248 185-120-10 & -11 PA-1700248 <br /> PHONE#P ExT. BOS DIST��RyIICrrTLOCATION CODE <br /> ( ) VV \ t <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby R8CC0 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 /> ( ) <br /> CITY Lodi STATE CA 'P95240 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> _ Knowlemre that all site and/or proiect 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 latvc. <br /> APPLICANT'S SIGNATURE: „yy D� � � DATE.- <br /> PROPERTY/BUSINESS OWNERO OPERAT /MANAGER OTHER AUTHORIZED AGENT <br /> 1fAPPLICANT is not the B/LL/NC PARTY proof of aUthorsZation 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 ai a time it is <br /> provided to me or my representative. _ A T�Cl1 s <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study vE® <br /> COMMENTS: <br /> 2018 <br /> �JOgQIJ <br /> HfAt y o pM�MSL <br /> ;rCHr hl 0 i <br /> ACCEPTED BY: jJ, EM LOYEE#: DATE: <br /> ASSIGNED TO: kMZ�., EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 5Z3 <br /> P 1 E: <br /> Fee Amount: 5--A Amount Pai 3d , oz) Payment Date 1p <br /> Payment Type Invoice# Check# ��� RecAived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />