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SERVICE REQUEST <br /> (SERVREO) Revised <br /> FACILITY ID # RECORD ID # I ICE # <br /> AT A <br /> FACILITY NAME FLOYD E. MOOD JR. SILLINC-PARTI x �.– <br /> SITE ADDRESS 12847 E . TOKAY COLONY ROAD /�A <br /> v <br /> CITY LODI CA ZIP 95240 <br /> OWNER/OPERATOR HERB NEWBERG BILLING PARTY <br /> DBA PHONE #1 f 209 > 465 -1780 <br /> ADDRESS 603 E, ESSEX, STOCKTON CA 95204 PHONE #2 f ) <br /> CITY STOCKTON STATE CA zip 95204 <br /> APN # Land Use Application # <br /> LOO <br /> Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR WONG ENGINEERS, INC . BILLING PARTY Y N <br /> DBA PHONE #1 f 209 ) 476 - 0011 <br /> MAILING ADDRESS 457$ FEATHER RIVER DR. , SUITE A FAX # f 209 ) 476 - 0135 <br /> CITY STOCKTON STATE C— ZIP 95219 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be bitted to the party identified as the BILLING PARTY on <br /> Page 1 of 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 <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal Laws. <br /> APPLICANT'S SIGNATURE : "U/ l� <br /> Ti tie: CIVIL ENGINEER Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any arta all results, geotechnical data and/or <br /> envirormental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request: /�SOIL/� /SUITABILITY REPORT <br /> �/ (� Service Cone <br /> Assigned to ���J kICK_// '41CA Employee # ��J y4 Date <br /> Date Service Completed Further Action Required: Y / N PROGRAM ELEMENT —ILA <br /> ' <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> �CT S7r G� C� ' 1Sf <br /> SUPV _/ / ACCT _��/ UNIT CLK _%_� <br />