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1% 210 00 3 )v AN JOAQ OIN• 1DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NA"'Pock Lane Partners, LLC. FACILITY ID # SERVICE REQUEST # Single Family Residential FAX# 119 E Weber Avenue ( ) �0� CITY Stockton STATE CA ZIP 95202 OWNER/ OPERATOR Pock Lane Partners, LLC, CHECK if BILLING ADDRESS ENVIRONMENTAL HEALTH DEPAPTAACkrr FACILITY NAME EMPLOYEE #: r DATE:' ASSIGNED TO: :S <S SITE ADDRESS 3009 DATE:"7 Pock Lane Stockton 95205 Street Number Direction Street Name city Fee Amount:304.00 Zip Code 0 — Payment Date Payment Type Invoice # HOME Or MAILING ADDRESS (If Different from Site Address) Check # Received By: 119 E Weber Ave��,ame Street Number CITY STATE ZIP CA 95202 Stockton PHONE #1 ExT. APN # LAND USE APPLICATION # (209 ) 939-9025 179-120-11 PHONE #2 Exr. BOS DISTRICT , LOCATION CODE v CONTRACTOR /SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NA"'Pock Lane Partners, LLC. PHONE# Ems (209) 939-9025 . COMMENTS%EGE' HOME or MAILING ADDRESS FAX# 119 E Weber Avenue ( ) CITY Stockton STATE CA ZIP 95202 BILLING ACKNOVyLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and, DLR50aws. n APPLICANT'S SIGNATURE: DATE: PROPERTY /BUSINESS OWNER❑ OPERATOR/ NfANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTI30RIZATIQN TO RELEASE INFQRMATI4N: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Surface and Subsurface Contamination Report Pi4YIV1'LN EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 COMMENTS%EGE' Y E® FEB 11 2021 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAPTAACkrr ACCEPTED BY: �—�j EMPLOYEE #: r DATE:' ASSIGNED TO: :S <S EMPLOYEE #: DATE:"7 Date Service Completed (if already completed). SERVICE CODE: 523 P E* 2603 r. Fee Amount:304.00 Amount Paid 0 — Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003