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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S�.bU� Sada <br /> OWNER/OPERATOR <br /> Arlene Lawry & Gwen Bender CHECK if BILLING ADDRESS 0 <br /> FACIUTYNAME Bender/Lawry Property <br /> SITE ADDRESS 31345 E. Grooms Rd. Oakdale <br /> Street Number I Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1515 W. Armstrong Rd. <br /> St StneA N m <br /> CITY Lodi STATE CA zip 95242 <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# <br /> (209 ) 369-3198 207-280-04 9N- I (9v Xk <br /> PHONE#2 E><r. BOB DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SE VICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex,. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME Or MAILING ADDRESS FAX# <br /> 407 W. Oak St. (209)369-0377 <br /> Cin' Lodi STATE CA zIP95240 <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,ST 'E and FEDERAL law ..� <br /> APPLICANT'S SIGNATURE- DATE: CD <br /> PROPERTY/BUSINESS OWNER LJ OPERATOR/MANAGER ❑ OTHER AUTRO DAGENT❑ <br /> /fAPPLLCANT is not the BILLINGPARTP 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 anc�l(„t�e.s�frtime it is <br /> provided to me or my representative. . A�(�G�`� <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study <br /> COMME TS: <br /> 6�s3�G <br /> Zy/,N 7 Com' la�"�WS' <br /> SAN30 <br /> NVIROMENTALNTY <br /> HEALTH DEPARTMFM <br /> ACCEPTED BY: B-I 1 e1A e EMPLOYEE#: DATE: D <br /> ASSIGNED TO: Ted <br /> `e1 ,d i O u EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S'C 5�✓ PI E: l <br /> Fee Amount: a O Amount Paid a • �� Payment Date G h 7 <br /> Payment Type�+ Invoice# Check# as 3 -� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />