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SAN JOAQUIN COUNTY ENVERONMENTAL HEALTH D_ ARTMEIR`1 0 O 10 J <br /> SERVICE REQUEST V <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S ()D3uLAL-,0_ <br /> OWNER I OPERATOR Henry Martin CHECK if BILLING ADDRESS <br /> FACILITY NAME Martin Property <br /> SITE ADDRESS 6103 W. Delta Ave. Tracy 95304 <br /> Street Number I Direction I Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) same <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (209) 456-7151 213-100-28 <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex'' <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS Fax# <br /> 407 W. Oak St. ( ) <br /> CITY 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: A, DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT I� CorJSuLTA-P —T <br /> Jf APPLICANT is not the BILGING 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 environmentaUsite 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. p <br /> TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination ReportREC <br /> COMMENTS: <br /> MAY 04 2021 <br /> SAN JOAQUIN <br /> HFAL1�}I p NMENT,gi 7Y <br /> EP��FNT <br /> ACCEPTED BY: Zf__114;7 1_ Z_. EMPLOYEE M DATE: �� a <br /> ASSIGNED TO: As EMPLOYEE#: DATE: S y a <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: a X03 <br /> Fee Amount: 30LI Amount Paid Payment Date (� <br /> Payment Type Invoice# Check# O Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />