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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Single Family Residential <br />FACILITY ID # SERVICE REQUEST # <br />-AP-oo-t)-(-P <br />OWNER / OPERATOR <br />Pock Lane Partners, LLC, CHECK if BILLING ADDRESS <br />FActurr NAME <br />SITE ADDRESS 3009 <br />Street Number Direction <br />Pock Lane <br />Street Name <br />Stockton <br />City <br />95205 <br />Zip Code <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />1 19 Street Number E Weber AvesgAame <br />CITY STATE ZIP <br />Stockton CA 95202 <br />PHONE #1 Err. <br />(209 ) 939-9025 APN # <br />179-120-11 <br />LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT 1 LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS 11 <br />BUSINESS NAM -rock Lane Partners, LLC. PHONE # <br />( ) (209) <br />EXT. <br />939-9025 <br />HOME or MAILING ADDRESS <br />119 E Weber Avenue <br />FAx # <br />( ) <br />CITY Stockton STATE CA ZIP 95202 <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 aws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />DATE: <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 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: Surface and Subsurface Contamination Report PAYMENT <br />COMMENTS: RECEIVED <br />FEB 1 1 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />EMPLOYEE #: <br />HEALTH DE7 R ENT <br />DATE: , ,,, i // j i ir <br />7 <br />--,'" / ACCEPTED BY: ............-- Z...., <br />ASSIGNED TO: S S <br />EMPLOYEE #: DATE: 01/4 /07 I <br />Date Service Completed (if already completed): SERVICE CODE: 523 <br />Fee Amount: $304.00 Amount Paid 411 () V — <br />P7 2603 <br />Payment Date /2,4/ --1,0 z 1 <br />Payment Type rz, Invoice # Check # 0 i Received By: <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003