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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # ❑ SERVICE REQUEST # CHECK If BILLING ADDRESS BUSINESS NAME 'i< DD 9 q 3V -5 -- -5 --OWNER/ OWNER/ OPERATOR ID Tracy Clarke CHECK If BILLING ADDRESS FACILITY NAME Clarke Property 369-0375 SITE ADDRESS 23702 N. Bruella Rd. I Date Service Completed (if already Completed): Acampo 95220 Street Number Direction Street Name STATE CA city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Payment Type same Invoice # Check # 1 C Street Number Street Name CITY STATE ZIP PHONE #'I EXT. APN # LAND USE APPLICATION # ( 209) 747-0089 007-340-01 PHONE #2 EXT. BOS DISTRICT 71 LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Review Surface & Subsurface Contamination Report ❑ Abby Racco CHECK If BILLING ADDRESS BUSINESS NAME ACCEPTED BY: PHONE # EXT. Live Oak Geo Environmental DATE: 209 369-0375 HOME or MAILING ADDRESS EMPLOYEE #: FAx# Date Service Completed (if already Completed): 407 W. Oak St. ( ) CITY Lodi STATE CA Z'P 95240 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE an FEDERAL la APPLICANT'S SIGNATURE: DATE: /0- 11--2- 1 PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MA AGER ❑ OTHER AUTHORIZED AGENT ISI C e NS U LTA AIT If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report PAYMENT COMMENTS: RECEIVED OCT 18 2021 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: �� �� h EMPLOYEE #: DATE: ASSIGNED TO: [ EMPLOYEE #: DATE: Date Service Completed (if already Completed): SERVICE CODE:a 3 PIE: 6p3 Fee Amount: 3p Amount Paid O Payment Date �p C Payment Type Invoice # Check # 1 C Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003