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SAN JOAQUIN COUNTY EWIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S� 001 1 -1�p lv <br /> OWNER/OPERATOR <br /> Ralph Timan CHECK if BILLING ADDRESS <br /> FACILITY NAME Timan Property <br /> SITE ADDRESS E. Critchett Ave. Tracy 95304 <br /> 451, 463, 46 <br /> Street Number Direeticm I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 451 E. Critchett Ave. <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Trac CA 95304 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (209 ) 836-2815 241-110-42 & -43 PA-1800101 <br /> PHONE'#Y ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS 407 W. Oak St. FAX# <br /> ( ) <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: I, 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, STAT d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: — G —I 1 k <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT ��lnln//-� <br /> If APPLICANT is not the BILLING 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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study Addendum RECEIVED <br /> COMMENTS: AUG 0 C 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> Z w <br /> ACCEPTED BY: M(?,��� EMPLOYEE M DATE: <br /> ASSIGNED TO: (\I T" 1 tNl P EMPLOYEE M DATE: 9—wv t;�? <br /> Date Service Completed (if already Completed): SERVICE CODE: `jZ,a P 1 E: Z(00% <br /> Fee Amount: co Paid Paid 3,9 c4 Payment Date g_ 6_ <br /> Payment Type G(L Invoice It Check# l 5s Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />