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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />Abby Racco <br />CHECK if BILLING ADDRESS <br />SERVICE REQUEST # <br />PHONE # EXT. <br />Live Oak Geo Environmental <br />S <br />003ULAV <br />OWNER / OPERATOR <br />Henry Martin <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Martin Property <br />( ) <br />SITE ADDRESS 6103 <br />W. <br />I <br />I Delta Ave. <br />Tracy <br />95304 <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />same <br />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209) 456-7151 <br />213-100-28 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Abby Racco <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />Live Oak Geo Environmental <br />209 369-0375 <br />HOME or MAILING ADDRESS <br />FAX # <br />407 W. Oak St. <br />( ) <br />CITY Lodi <br />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 <br />and �/c <br />FEDERAL laws. <br />/ <br />APPLICANT'S SIGNATURE: z'/f -4-,l DATE: <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT CONSVLTMv-T <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. PAU,._ <br />TYPE OF SERVICE REQUESTED: <br />Review Surface & Subsurface Contamination Report <br />COMMENTS: `" <br />MAY <br />0 4 2021 <br />SAN JOAQU! <br />NT <br />ACCEPTED BY: 1 1 . EMPLOYEE M DATE: L� <br />ASSIGNED TO: As EMPLOYEE M DATE: <br />Date Service Completed (if already completed): SERVICE CODE: ST P! E: a b0� <br />Fee Amount: � 30LI Amount Paid f Payment Date 7 / <br />Payment Type 0.01rInvoice # Check #yD Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />