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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 00 io- A 3 <br /> OWNER/OPERATOR <br /> Corey Lee CHECK if BILLING ADDRESS <br /> FACILITY NAME Lee Property <br /> SITE ADDRESS3852 & 3858 S. Stockton <br /> Mourfield Ave 95206 <br /> Street Number Direction $treat Name CLtx Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 521713th St. <br /> c/o Gar Madsen Welt En ineerin Street NumbeStreet Name <br /> CITY Modesto STATE CA ZIP 95354 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 526-1515 175-240-27 <br /> PHONE#2 EXT. BOS 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. ( ) <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 identifiedAn this form. <br /> I also certify that I have prepared this application an t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE an DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: //Z7/1 cJ <br /> PROPERTY/Bl1SINESS OWNER OPERATOR/MANAGER ❑ OTHER AtTTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,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 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. <br /> TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Re <br /> COMMENTS: MEMEIVED <br /> APR 01 2019 <br /> JOAQUIN COUNTY <br /> lJ F ENVIRONMENTAL <br /> �j HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: '177 17 <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:/' i7 <br /> Fee Amount: Amount Paid Payment Date I <br /> Payment Type Invoice# Check# `t�� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />