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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 GeoEnviron mental <br />PHONE # EXT. <br />209 369-0375 <br />OWNER / OPERATOR <br />Brent & Janelle Holfman <br />11771 <br />CHECK if BILLING ADDRESS LU <br />FACILITY NAME Holfman Property <br />407 W. Oak St. <br />SITE ADDRESS 7272 <br />E. <br />Lathrop Rd. <br />--[ <br />Manteca <br />95336 <br />Street Number <br />Direction <br />Street Name <br />Payment Type <br />Ci <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 12191 <br />E. Louise Ave. <br />Street Number <br />Street Name <br />CITY Manteca <br />STATE CA ZIP 95336 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209) 479-5410 <br />218-050-01 <br />PHONE #2 EXT. <br />BOS DISTRICT IJJ <br />---][ <br />LOCACT�ION CODE <br />q <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />❑ <br />Abby Racco <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Live Oak GeoEnviron mental <br />PHONE # EXT. <br />209 369-0375 <br />HOME or MAILING ADDRESS <br />ASSIGNED TO: <br />FAX # <br />407 W. Oak St. <br />DATE:(� <br />( ) <br />CITY Lodi <br />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 d FEDERAL laws. <br />APPLICANT'S SIGNATURE: 0 <br />DATE'{ <br />]PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT LXJ C*-SyLTilk" 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 envl ssessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available�e time it is <br />provided to me or my representative. RECEIVED <br />TYPE OF SERVICE REQUESTED: <br />Review Surface & Subsurface Contamination Report APR <br />COMMENTS: <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #:DATE: <br />Z <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE:(� <br />Date Service Completed <br />if already completed): <br />SERVICE CODE:Z z <br />P 1 E: <br />Amount: <br />OFee <br />Amount Paid -- <br />Payment Date) <br />Payment Type <br />Invoice # <br />Check # l <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />