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SAN,JaAQUINk UNTY ENVIRONMENTAL HEALTH ' PARTMENT <br /> SERVICE REQUEST PA2100252 <br /> p usiness or Property FACILITY ID# SERVICE REQUEST# <br /> 00 0 3V-5-- <br /> OWNER/OPERATOR <br /> Tracy Clarke CHECK if BILLING ADDRESS <br /> FACILITY NAME Clarke Property <br /> SITE ADDRESS 23702 N. Bruella Rd. Acampo 95220. <br /> Street Number Direction Street Name cityZI 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) 747-0089 007-340-01 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS❑ <br /> EXT. <br /> BUSINESS NAME Live Oak GeoEnvironmental (209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <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 JDAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE an FEDERAL la <br /> APPLICANT'S SIGNATURE: DATE: 10 - I <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MA AGER ❑ OTHER AUTHORIZED AGENT C#,-JS ULTA NT <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 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. <br /> TYPE OF.SERVICE REQUESTED: Review Surface & Subsurface Contamination Report PAYMENT <br /> COMMENTS: RECEIVEDF <br /> OCT 18 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: — _ Z_, EMPLOYEE M DATE: <br /> ASSIGNED TO: I— EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P 1 E: <br /> Fee Amount: J Ll Amount Paid O Payment Date �p C2,c 2�/ <br /> Payment Type Invoice# Check# 1 l Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />