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SAN JOAQUIN r -`LINTY ENVIRONMENTAL HEALTH 'PARTMENT <br /> SERVICE REQUESTFrJ22 O <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# " <br /> ti <br /> OWNER'/OPERATOR <br /> Calvin Tate CHECK If BILLING ADDRESS® <br /> FACILITY NAME Tate Property <br /> SITEADDRESS 11880 E. Ada Ave. Stockton 95215 <br /> Street NumberT Direction Street Name city Zip Code <br /> HOME or,MAILING ADDRESS (If Different from Site Address) 2932 Canal Dr. <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Stockton CA 95204 <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> ( 650): 520-7332 103-280-33 <br /> PHONE#2; EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS'❑ <br /> BUSINESS NAME PHONE# Exr. <br /> Live Oak GeoEnvironmental (Pnq) 369-0375 <br /> HOME Or MAILING ADDRESS Fax# <br /> 407 W. Oak St. <br /> ( ) <br /> C'n 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, STATEapd.FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: (- 21 -22 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/4ANAGER ❑ OTHER AUTHORIZED AGENT 13 C0WS,4.T?r"-r <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. PA <br /> TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report <br /> COMMENTS: <br /> ��A�� <br /> N FNS Q4//� <br /> Ti 11?z R�OIJN7?' <br /> Ms <br /> ACCEPTED BY: EMPLOYEE#: _ I} DATE: <br /> W a <br /> ASSIGNED TO: L EMPLOYEE#: DATE: f , <br /> Date Service Completed (if already completed): SERVICE CODE: l P.1 E: ' <br /> Fee Amount: (j Amount Pal �o-q U� PaymentVDate Z <br /> Payment Type i�)61L- Invoice# Check# 1 LN4,p -ILL Received By: <br /> EHD 48=02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />