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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �►2a�?3232 <br /> OWNER/OPERATOR El <br /> Van Groningen CHECK if BILLING ADDRESS <br /> FACILITY NAME Van Groningen Property <br /> SITE ADDRESS 13300S. Jack Tone Rd. Manteca 95336 <br /> Street Number Direction I Street Name city Zip C009 <br /> HOME or MAILING ADDRESS (If Different from Site Address) 15176 Jack Tone Rd. <br /> Street Number Street Name <br /> CITY Manteca STATE ZIP <br /> CA 95336 <br /> PHONE#1 E"T• APN# LAND USE APPLICATION# <br /> (209 ) 982-4349 203-040-03 PA-1500144 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco <br /> CHECK N 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. (209)369-0377 <br /> CITY Lodi STATE CA Z'P 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,STATE and FEDERAL laws. p <br /> APPLICANT'S SIGNATURE: Pzt d&n AJ'1p rLcrtq � DATE: /-Z3-/J— <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> ff APPLicANT is not the BiLLlNG PARTY 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 i5 available and at the same time it i5 <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study R <br /> COMMENTS: �c / S �v <br /> to I � q p28 <br /> ACCEPTED BY: 6XIA <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: � 1j lS <br /> Date Service Completed (N airmdyIeted): SERVICE CODE: C �v PIE: 200 <br /> Fee Amount: 7'W Amount Pai arlv0 d-b I Payment Date `(' XeLc <br /> Payment Type . Invoice# check# Itacelv6d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />