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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 i OPERATOR <br /> Patricia Van Groningen CHECK if BILLING ADDRESS <br /> FACILITYNAME Van Groningen Property <br /> SITE ADDRESS 12151 S. Jack Tone Rd. Manteca 95336 <br /> Street Number Direction I Stre t Name Ci 2i Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 15176 Jack Tone Rd. <br /> Street Number Stloot Nam. <br /> CITY Manteca STATE CA ZIP 95336 <br /> PHONE#1 Exp. APN# LAND USE APPLICATION# <br /> (209 ) 982-4349 201-140-02 PA-1500145 <br /> PHONE#2 Exr BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK MBILLING ADORESS� <br /> BUSINESS NAMELive Oak GeoEnvironmental P"2009 09 E.,. <br /> 2 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. (209)369-0377 <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 /> 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: At 6" DATE: q--23-1 <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT[3 <br /> IfAPPLICANT is not the BILLING PARTY proof of authorizadon 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 a t1e time it is <br /> provided to me or my representative. N <br /> TYPEOFSERVICEREQUESTED: Review Soil Suitability Study VED <br /> 2RP . <br /> CDM Nr 2015 <br /> � <br /> p1 � <br /> n -J�IVL/I"` � (1I� SANJOqQUIN <br /> �✓ 1 j a gryu a ENVIRN AUNTY <br /> H <br /> STN DEE ENTAL <br /> ACCEPTED BY: EMPLOYEE M DATE: 15 <br /> ASSIGNED TO: Q Cil C-i EMPLOYEEM DATE: <br /> Date Service Completed (N already eo ): SERVICECODE: � jj 2�j PIE: <br /> Fee Amount: -�IbAmount Paid (o0.O(D Payment Date ZV S <br /> Payment Type Invoice# Check# Recei d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />