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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/OPERATOR Joan Trinkle c/o Schack & Co. XD <br /> CHECK If BILLING ADDRESS <br /> FACILITYNAME Trinkle & Boys Property <br /> SITE ADDRESS 31199 S. Koster Rd. Tracy ��LI <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1025 Central Ave. <br /> Street Number Street Name <br /> CITY Tracy STATE CA zip 95376 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 835-2178 255-310-40 6 d D 3 8 (5&\,) <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak Geo Environmental 209 369-0375 <br /> HorJIE or MAILING ADDRESS FAX# <br /> 407 W. Oak St. (209)369-0377 <br /> CITY 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 /> COUNTS'Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ATE: l� <br /> PROPERTY/BUSINESS OWNER❑ OPE R/ ANAGER 13OTHER AUTHORIZED AG T❑ <br /> If APPLICANT is not the B1LLxG PARTY 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. <br /> TYPE OFSERVICEREQUESTED: Review Surface & Subsurface Contamination Report e <br /> COMMEN <br /> S: 4 <br /> E 15 <br /> 0�^4 pOV� ��0ct% <br /> ACCEPTED BY EMPLOYEE#: DATE: P <br /> ASSIGNED TO: �� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:���' P I E: <br /> Fee Amount: b. Amount Paid $��Q, Payment Date s 1 l5 <br /> Payment Type�A.CdC� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />