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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Live Oak GeoEnvironmental <br />�F <br />C �5 <br />'ZOA0 v <br />OWNER /OPERATOR <br />Jacklyn Shaw <br />CHECK if BILLING ADDRESS El <br />FACILITY NAME Shaw Property <br />407 W. Oak St. <br />SITE ADDRESS 15766 <br />N. <br />DeVries Rd. <br />STATE CA z'P 95240 <br />Lodi <br />F95242 <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Payment Date <br />same <br />Invoice # Check # <br />Received By: <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 562) 233-7300 <br />025-170-03 <br />PA - 2( p10 Z a <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />�l11 <br />G i <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />❑ <br />Abby Racco <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Live Oak GeoEnvironmental <br />�F <br />C �5 <br />PHONE # EXT. <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 and EDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT GduS vL-mtAvT <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, t, 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. <br />TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report <br />Aq <br />COMMENTS: <br />IWI <br />00IeZ6 <br />�F <br />C �5 <br />�O 021 <br />k`r tR H�NCOV <br />MFN4 NAY <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: )2 1ZvT <br />ASSIGNED TO: / v <br />EMPLOYEE #: <br />DATE: /a S- a <br />Date Service Completed (if already Completed): <br />SERVICE CODE:a 2 <br />J <br />P I E: d J z <br />Fee Amount: 3 v Ll <br />Amount Paid V <br />Payment Date <br />Payment Type <br />Invoice # Check # <br />Received By: <br />LPI <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />