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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S <br /> OWNER/OPERATOR <br /> Brad Goehring, Berghill, LLC, et. al CHECK if BILLING ADDRESS x❑ <br /> FACILITY NAME Harney Lane Property <br /> SITE ADDR S <br /> P0745 & 23649 E. Harney Ln. Lodi 95240 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) P.O. Box 739 <br /> Street Number Street Name <br /> CITY Linden STATE CA zip 95236 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 609-8280 067-040-01 & -09 <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) LI C <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 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 /> c'TY 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,STATE and FEDER���ALjjjlaws. <br /> APPLICANT'S SIGNATURE: /`c DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® L6NSuiT�a./T <br /> 1f 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. PA <br /> TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report ECE <br /> COMMENTS: <br /> AUG <br /> 1 G O <br /> V U 20�p <br /> SzlvAN <br /> V/R�UtN CO�� <br /> lip gLrHOFPA�NZA L�ry <br /> ACCEPTED BY: EMPLOYEE#: DATE: 7a v <br /> ASSIGNED TO: /`f EMPLOYEE#: DATE: K 7 aJv7� <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P I E: d C03 <br /> Fee Amount: 5 D Amount Paid �bL��� Payment Date '�'17 Zb <br /> Payment Type 117K- Invoice# Check# 1�3� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />