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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 i2©O 9Z-1 soot <br /> OWNER/OPERATOR <br /> Sherman Chiu CHECK if BILLING ADDRESS LQ6.1 <br /> FACILITY NAME Chiu Property <br /> SITE ADDRESS 8744 S. Roberts Rd. Stockton 95206 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3314 Cesar Chavez St. <br /> Street Number Street Name <br /> CITY San Francisco STATE CA Zip 94110 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (415) 279-1290 162-100-03 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( 1il 3 11 �' <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EM' <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 Ezw[RONNIENTAL 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPL/CANT 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 DEPARTNIENT as soon as it is available and at the same time it is <br /> provided to nye o.nay represen-Laiive. <br /> .11 <br /> TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report R N <br /> COMMENTS: vk�D <br /> OCT 0 2020 <br /> HEA TOF? C (J <br /> H�FPgRTME <br /> ACCEPTED BY: EMPLOYEE#: DATE: /0vl71d0';0 <br /> ASSIGNED TO: < S EMPLOYEE M DATE: /1A�Oldo"?C> <br /> Date Service Completed (if already completed): SERVICE CODE: st?3 P/E: a 60 3 <br /> Fee Amount: 3 0 i-' Amount Paid Payment Date 1 O aO 2-0 <br /> Payment Type Invoice# Check# /L I Received By: <br /> 04A e <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />