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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 /> Anival De Casas CHECK if BILLING ADDRESS <br /> FACILITY NAME De Casas Property <br /> SITE ADDRESS 4338 1 N. Homer St. Stockton 95215 <br /> Street Number Direction Street Name Ci Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 7191 E. Worth St. <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95206 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 603-7768 c/o Bob Santana 087-130-42 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak Geo Environmental 209 369-0375 <br /> HOME or MAILING ADDRESS Fax# <br /> 407 W. Oak St. <br /> ( ) <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 ENV-iRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business/anh <br /> ed on this form. <br /> I also certify that I have prepared this applicatjt the wor tc be perf ed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATaAL laws: <br /> APPLICANT'S SIGNATURE: l 3 zG�4 <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ 9�ERATOR/ NAGR ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT is not th ISILLING P RTY Of of��Pizdtion to sign is required Title <br /> AUTHORIZATION TO RELEASE INFO"AT16N: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby auth ize 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: Revliew/ Soil SuitabilityStudyS cA) S <br /> COMMENTS: gJ[J\\ I^ <br /> 1 UC'AY CC.ri' i <IyJ Se-ivlt?�vla <br /> ss Loa�� S / h,b� 65S 6�, 'IdPFs <br /> c%}td ;1(,A <br /> 13, zoto PAY4.1�V <br /> TRECE/ D <br /> ACCEPTED BY: r� EMPLOYEE#: DATE: 020 <br /> ASSIGNED TO: v e I EMPLOYEE#: J IVVIRONIMF OV <br /> JrA <br /> Date Service Completed (if already completed): SERVICECODE: ��3 P . Rte' .2 <br /> Fee Amount: �,�� Amount Paid 0 Payment Date (� 2� <br /> Payment Type Invoice# Check# Q l Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />