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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Jq <br /> OWNER/OPERATOR <br /> Aleck Dambacher CHECK If BILLING ADDRESS El <br /> FACILITY NAME Dambacher Property <br /> SITE ADDRESS 27445 N. New Hope Rd. Thornton <br /> Street Number Direction Stmel Nae CIftV Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1165 Scenic Drive, Suite B <br /> c/o O'Dell En ineeri i street Number Street Nam <br /> CITY Modesto STATE CA ZIP 95350 <br /> PHONE#1 APN# LAND USE APPLICATION# / <br /> (209 ) 571-1765 O'Dell 001-210-33 _1 ' -C <br /> PHONE#2 ExT SOS CIS Loc LOCATION CODE <br /> ( ) V <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby RaCCO CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ' <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"'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 applicaf and that the Ierfo d wil a done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST an F <br /> APPLICANT'S SIGNATURE: DATE: IO - 21 —/.S <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> IfAPPL7cANT is not the B1LLi,vG PAR pivrofof 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 is available and at the same time it is <br /> provided to me or my representative. c <br /> TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report R C <br /> COMMENTS: `.,10<k j',w,;Nv VLAAY OCT Fp <br /> ( L-Go v^ sgNdp 26'ZOIS <br /> \ N�CTyD M Np ARaq�N)Y <br /> ACCEPTED BY: EMPLOYEE M DATE: q� <br /> ASSIGNED TO: EMPLOYEE#: DATE. <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: ?-(e0--:> <br /> Fee Amount: ZWQ I Amount Pai �(,Q.b d Payment Date l <br /> Payment Type Invoice# I Check# 3313 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />