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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT P t/ <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G � ?a6i L� <br /> OWNER/OPERATOR Tem Horsley / —1;J ✓�S d El <br /> d Yl/'^Orl� � 'T� CHECK if BILLING ADDRESS <br /> FACILITY NAME Horsley Property kkk/// `�-r IIIVUWW�WNVlliiill 11 <br /> SITE ADDRESS 6100 S. Stanley Rd. Stockton 95215 <br /> Street Number I Di....u..,, Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) same <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (209) 487-3283 187-070-28 PA-1600225 <br /> PHONE#2 ExT. BOIS 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 GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAx# <br /> 407 W. Oak St. I ) <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: L the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENviRoNNmNTAL HEALTH DEPARTNIENT 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 1 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,STATE and FEDERAL,laws. 7 / <br /> APPLICANT'S SIGNATURE: / 1// � DATE; (� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAYPl/CAN is not the 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 /> inforination to the SAN JoAQuLN CouNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. m <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study ?S`"C L 04Z <br /> ,. <br /> COMMENTS: <br /> APR 2 5 2011 <br /> SAN JOAQUIN COUNTY <br /> ` ENVIRONMENTAL <br /> 1 .HEALTH DEPARTMENT <br /> ACCEPTED BY: 12W <br /> EMPLOYEE M DATE: <br /> ASSIGNED TO: -/-1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: O <br /> Fee Amount: Amount Paid c1 7.-I$ ,,D Payment Date Lf I 2!S <br /> Payment Type(�k,,,.94, Invoice# Check# 2gS Received By:`� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />