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SAN JOAQUIN COUNTY ENNTRONWNTAL HFALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> s2Co�S�? <br /> OWNER(OPERATOR Arlene Lawry & Gwen Bender <br /> CH40K N EILLeIG ADDRES.9 <br /> FACanYNAME Bender/Lawry Property <br /> SITE ADDRESS 31345EG Rd. Oakdale <br /> S Stmet MIN <br /> HOME or MALL ING ADDRESs (h ) 1515 W. Armstrong Rd. <br /> Strmt N perc°YLodi STATE CAzip 95242 <br /> PHONE#1 LAND USE APPUOATION0 <br /> (209 ) 369-3198207-280-04PHONE#2 BOB WSTRIOT LCCA110N CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby RaCCO CHECK K BILLING AODRE�sg❑ <br /> BUSINESS NAME PHONE# Far. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME Or MAILING ADDRESS FA%# <br /> 407 W. Oak St. (209 369-0377 <br /> CITY Lodi STATE CA zap 95240 <br /> BILLING A,CjQLQMg FL)CEI► ENT; I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/br project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to roe or my business as ideutif ed on thia form ' <br /> I also certify tbat I have prepared this application and that the work to be performed will be done in accordance with all SAN 70AQUIN <br /> COLW Y Ordinance Codes,Standards,STATE and FEDERAL,laws. / <br /> APPLICANT'S SIGNATURE: )DATA: IJ111/y/jy' <br /> PROPERTY/BOSLHESSOwNr,RC1Y OPERATOR/MANAGER O OTBRR.Aur OMZLIDAGSNT❑ <br /> 17fAFFL7CAVr is nor the� Mg–PAM proof of authorization to sign is regi lred Xirls <br /> AUTHOrtIZATI0N To RELFA ILSO, MATION;When applicable,1,the owner or operator of the property located at the <br /> above site address, hereby autboruz the release of any and all results, geotechnical data and/or envirotmtentaUsite assessment <br /> Wormadon to the SAN IOAQU N COUNTY ENviRONMENTAL HEALTH DEPARTMENT as Soon as it is available and atfYr time it i8 <br /> provided to me or my representative. !"� <br /> TYPE OF SERVICE REQUESTED: Review Surface&Subsurface Contamination Report Fj <br /> COMMENB; <br /> +�`�6_ [Zb I (� SAN'jo 09e015 <br /> I�WM' HF� QUIAI <br /> �l,jr 41 COON <br /> v H OFPARTMC ry <br /> FNT <br /> ACCEPTED By; EMPLOYEEM DALE: <br /> Aaard NED TO:;Q eJ10 PO(A In EMPLOYEEM DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �;� — .P(E; <br /> Foe Amount: /_nom Amount Pah' <br /> ��0, b D Payment Date �f S <br /> Payment Type ALV Invoice# Check# �'L-7 Received By: <br /> EHD 48-02-025 R <br /> REVISED 11/17/2003 SR FORM(Golden o <br />