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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 <br /> James Gwerder CHECK If BILLING ADDRESS X❑ <br /> FACILITY NAME Lehman Road Property <br /> SITE ADDRESS 28801 S. Lehman Rd. Tracy <br /> Street Number DI-11 �� Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 11847 W. Valpico Rd. <br /> Street Number Street Name <br /> CITY Tracy STATE CA ZIP 95376 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 483-1298 253-330-33 1 00 265 MS <br /> PHONE#2 Ex . BCS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQ UESTOR <br /> REQUESTOR <br /> Abby Rocco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME Or MAILINGADDRESS 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 /> COUNTY Ordinance Codes,Standards,STAT and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: —ACzaDATE: 9 -24 -1 (P <br /> PROPERTY/BUSDHESs OWNER❑ OPERATO /MANAGER ❑ OTHER AUTHORIZED AGENT❑ consultant <br /> IJAPPLicANT is not the BILLING 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 JOAQUUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report (QFC . - <br /> COMMENTS: C P b <br /> z�y�/s Rpvw O�cle�,i9f <br /> 1 orf �b IZt�GYL�,J (go /ys"� heACTy a�p F�oO^'ry <br /> 1 <br /> vvv �9/TMENT <br /> ACCEPTED BY: 'a MQ,///I/1 O EMPLOYEE#: DATE: 2Q)P/ <br /> ASSIGNED TO: -FOS i0 10S EMPLOYEE#: DATE: 2U/ <br /> Date Service Completed (if already completed): SERVICE CODE: S G 1 � P)'E: a 0 <br /> Fee Amount: g-n I Amount Pa ,?- Q D I <br /> Payment Date S/ <br /> Payment Type Invoice# Check# d3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />