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WV 9£:6 51OZ/91/9 £3o I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> : :1 �� �Rc)0-7 <br /> OWNER/ OPERATOR <br /> Marc Marchini CHECK If BILLING ADDRESS <br /> FACILITYNAME A.M. Farms <br /> SITE ADDRESS 9010 W. Howard Rd. Stockton 95206 <br /> Street Number Direction Street Name Cil Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ear. APN# LAND USE APPLICATION# <br /> (209 ) 462-1185 189-190-04&-07; 189-160-12&-23 _ S p wed Z <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> l ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Rocco CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# En. <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 ZIP 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 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. <br /> APPLICANT'S SIGNATURE:c i� DATE: O <br /> PROPERTY/BUSINESS OWNERiO OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLlCANT is not the B1LLINGPARTY proof of 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 environmentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Mme time it is <br /> provided to me or my representative. Pip <br /> TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report FIVE <br /> COMMENTS: - 4 Z015 <br /> � J <br /> I^ �U <br /> ACCEPTED BY: EMPLOYEE#: DATE: I �S <br /> ASSIGNED TO: A 'h VV EMPLOYEE#: A 'p )'{ s <br /> Date Service Completed (if already completed); SERVICE CODE: SG PIE; <br /> Fee Amount: Z(P� �j Amount Pal a(eD �7) ayment Date + `� <br /> Payment Type Invoice# Check# /a7 K> Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> £61£1=5�W*yat1616(3*R..lo[o0/03ui7[00c[-Suuo[o0'MMM//:ciuT4 amloid$ul.i0[00[oAEd MEd <br />