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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SR ob ��� 3� <br /> OWNER/ OPERATOR Joseph & Linda Martinez CHECK if BILLING ADDRESS <br /> FACILITYNAME Martinez Property <br /> SITE ADDRESS 303S. Reid Ave. Linden <br /> Street Number Direction I Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1804 Sherwood Ct. <br /> Street Number Street Name <br /> CITY Santa Rosa STATE CA zip 95405 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> 1707 1 483-4716 183-360-08 PA-1500250 <br /> P1oRE#2 --- Ems— BOS DISTRICT LOCATION CODE I <br /> ( ) J <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REDUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> PHONE# ExT. <br /> BUSINESS NAME Live Oak GeoEnvironrnental 209 369-0375 <br /> HOME or MAILING ADDRESS FA%# <br /> 407 W. Oak St. (209 )369-0377 <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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,StandarATE and FEDERAL la <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BuSINPSS OWNER PERATOR/MA ' GER ❑ OTHERAUT RIZEDAGENT❑ <br /> IfAPPLICA.NT is no e BILLING 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 i5 available and at the Same time It is <br /> provided to me or illy representative. PAYMFNT <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study RECEIVED <br /> COMMENTS: �.I MAY 1 0 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> �7t HEALTH DEPARTMENT <br /> ACCEPTED BY:':-�, r/, EMPLOYEE#: DATE: 51 10 <br /> ASSIGNED TO: E-,C e, EMPLOYEE#: DATE: 5- i i)' 1 <br /> Date Service Completed (if already completed): SERVICE CODE: z P/E: <br /> Fee Amount: ��PU_ Amount Paid a 6 Payment Date <br /> Payment TypeInvoice# Check# a S Received By: <br /> EHD 46-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />