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RECE WED <br />SAN JOAQUIIN COUNTY ENVIRONMENTAL HEALT.EPARTMENT APR 21 2017 <br />SERVICE REQUEST FVPflinjrr <br />Type of Business or Property <br />Vacant <br />FACILITY ID # <br />,,. , 0 , , <br />SERVIRMKATMES <br />," - ''-} Z. (/ 7 <br />OWNER / OPERATOR <br />SHECK if <br />Levand Family Trust & Levand Bright Family Trust - Paula Levand - Trustee / Joan Konkel- I rustee <br />BILLING ADDRESS <br />FACILITY NAME <br />Levand Bright Property <br />SITE ADDRESS <br />3 Street Number <br />East <br />Direction <br />11th Street <br />Street Name <br />Tracy <br />City <br />95376 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />24692 Street Number <br />Sand Wedge Lane <br />Street Name <br />Crry STATE ZIP <br />Valencia CA 91355 <br />PHONE #1 Err. <br />( 661 ) 904-2133 <br />APN # LAND USE APPLICATION # <br />233-369-18 NA <br />PHONE #2 ExT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Brian Millman - Advanced GeoEnvironmental, Inc. CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Advanced GeoEnvironmental, Inc. <br />PHONE # <br />( 209) 467-1006 <br />EXT. <br />HOME or MAILING ADDRESS <br />837 North Shaw Road <br />FAX # <br />( 209 ) 467-1118 <br />Ow Stockton STATE CA ZIP 95215 <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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: (Brian Millman) DATE: 4/21/17 <br /> <br />PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER El OTHER AUTHORIZED AGENT 121 <br /> <br />Project Geologist <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: Grout Inspection - Soil Boring Permit <br />COMMENTS: <br />ACCEPTED BY: • ( d EMPLOYEE #: , / , DATE: 2 / 2,, c- 17 , <br />ASSIGNED TO: ,., EMPLOYEE #: 4 ' DATE: I <br />Date Service Completed (if already completed): ( a I <br />, . SERVICE CODE: C - <br />) <br />PIE: , 1 c <br />) Fee Amount: 1 Amount Paid , i ---; Payment Date <br />Payment Type Invoice # <br /> <br />Check #' " ( f ' ,... 4.- ) ...% Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003