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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Gerard Warmerdam CHECK if BILLING ADDRESS X❑ <br /> FACILITY NAME Warmerdam Property <br /> SITE ADDR�S,S95O & 19701 N• Disch Rd. Lockeford 95237 <br /> y Street Number Direction Street Name Ci Ziv Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 19950 N. Disch Rd. <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Lockeford CA 95237 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 334-4904 1 019-150-22 & 019-160-051 A_ I quGzzG <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. (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 appli ion and that the rk to be per ed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar , TA an E AL 1 s. / <br /> APPLICANT'S SIGNATURE: T'z DATE: [ / <br /> PROPERTY/BUSINESS OWNED 91- OPERATOR/MANAGER ❑ OTHER AUTHORIZED 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 enviro site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available/Ia1 site <br /> it is <br /> provided to me or my representative. IWOP, <br /> TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report S n <br /> COMMENTS: SAND �7 <br /> H ENV/Ro�iN COU/y <br /> F'gCTy�FpMR MINTY <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: 1711 <br /> Date Service Completed (if already completed): SERVICE CODE: -j/3 P I .. <br /> Fee Amount: t Amount P i D� Payment Date <br /> Payment Type Invoice# Check# !l0(O Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />