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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Se ur%j�qo�tp <br /> OWNER/OPERATOR <br /> Noelle Ilayan CHECK If BILLING ADDRESSE] <br /> FACILITYNAME Ilayan Property <br /> SITE ADDRESS 1914 S. Sinclair Ave. Stockton 95215 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1833 Silver Almond Ln. <br /> Street Number Street Name <br /> CITY STATE Zip <br /> Sacramento CA 95834 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (925) 813-1184 173-250-21 <br /> PHONE#2 Ex-r. BOS DISTRICT I LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAx# <br /> 407 W. Oak St. <br /> ( ) <br /> CITY Lodi STATE CA ZIP 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 /> n oel l e i l a a n Digitally signed by noelle ilayan <br /> APPLICANTS SIGNATURE: Y Date:2021.08.05 11:22:53-07'00' DATE: <br /> PROPERTY/BUsrNESs OWNER Ell OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tarte <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 /> infonnation 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: Review Surface & Subsurface Contamination Report M <br /> At— <br /> COMMENTS: VC <br /> qtIG 6 D <br /> SANJo 2021 <br /> hEA Ty�qp COO <br /> q A� <br /> ACCEPTED BY: EMPLOYEE M DATE: �/ T <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <,-3 P I E: p'7(�03 <br /> Fee Amount: j� Amount Pai 30[4 66 Payment Date 8 �� <br /> Payment Type Invoice# Check# l Z �33�b Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />