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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S2u�7��37 <br /> OWNER/OPERATOR <br /> Faramarz "Fred" Foroutan CHECK if BILLING ADDRESS <br /> FACILITY NAME Foroutan Property <br /> SITE ADDRESS 8505W. Stockton St. Thornton 95686 <br /> Street Number Direction Street Name Ci Zio Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 1280 Rio Hondo Dr. <br /> Street Number Street Name <br /> CITY San Jose STATE CA zip 95120 <br /> PHONE#1 EXT. 7C01 <br /> # LAND USE APPLICATION# <br /> (408) 202-7484 -190-43 p pr-I!-1500 L f� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CX)LA <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 z'P 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, STAT d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: " -2- <br /> PROPERTY/ <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 55 C-MA.S U <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 tl ,� time it is <br /> provided to me or my representative. � F <br /> TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report /yle <br /> COMMENTS: <br /> JO 1 ?0 <br /> hM�io NMFCOU <br /> 44 18 <br /> FpgR �Y <br /> ACCEPTED BY: MU� � � EMPLOYEE#: DATE: <br /> ASSIGNED TO: WV) EMPLOYEE#: DATE: -CT- -1116 <br /> Date Service Completed (if already completed): SERVICE CODE: �1�3 P1 E;20 > <br /> Fee Amount: 3D���� Amount P 30 Payment Date S2 <br /> Payment Type Invoice# Check# �5�� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />