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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5R o0`�755� <br /> OWNER/OPERATOR <br /> William Rand CHECK If BILLING ADDRESS <br /> FACILITY NAME Rand Property <br /> SITE ADDRESS 277 N Sibley Rd. Stockton (,y'zt� <br /> Street Number Direction Street Name cityZI C de <br /> HOME or MAILING ADDRESS (If Different from Site Address) C/o John Shoup P.0. BOX 658 <br /> Street Number Street Name <br /> CITY Clements STATE CA ZIP 95227 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (209) 670-4275 W lliam 0" 103-290-30 PA-1700035 <br /> PHONE <br /> O� ) JohN SI~ave BOS DIST RIC0%--� LOCATION CODE <br /> 6 CONTRACTOR/ SERVICE REQUESTVVOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ear• <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 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,S d FEAEaws. <br /> APPLICANT'S SIGNATURE: DATE: 5-5- <br /> PROPERTY/BUSINESS OWNER❑ OPERATORI AGER ❑ OTHER AUTHORIZED AGENT W Co✓$014Ant <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INEORMATIQN: 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. PAYml <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study lveclelveo <br /> COMMENTS: 4 Agh;. 7 <br /> 4(,lyb�tl MAY C 101) <br /> �E fdL'7 K�vi LaclF>� '"t SAIV,IOAQLI/N <br /> COLINTY <br /> u-5 RON <br /> HEAL N/D PAR 7-AL <br /> EVr <br /> ACCEPTED BY: �LY�CftQ41d� EMPLOYEE#: DATE: -z4- �)7 <br /> ASSIGNEDTO: -�W � EMPLOYEE#: DATE: 57-Z.{k.. 2017 <br /> 7 <br /> Date Service Completed (if already completed): SERVICE CODE: 5)30 P/ 26ol <br /> Fee Amount: 27'3,00 Amount P ' a.�8, 0 (� Payment Date S 1`7 <br /> Payment Type Invoice# Check# Received By: abL <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />