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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SRGOSCDI53 <br /> OWNER/OPERATOR <br /> Carlos Morenos CHECK if BILLING ADDRESS® <br /> FACILITY NAME Morenos Property <br /> SITE ADDRESS 956S. Oro Ave. Stockton 95215 <br /> Street Number Direction Street Name cit. Zip 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 /> (831 ) 226-4827 1157-281-05 PA-2200115 MS <br /> PHONE#2 EXT• BOS DISTRICT LOCA ON CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> Live Oak GeoEnviron mental 209 369-0375 <br /> HOME or MAILING ADDRESS FAx# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE CA Lp 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: DATE: 1 - 13 - -2-3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® G o NS✓t.T-A V-r <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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 T <br /> COMMENTS: JAN <br /> 13 21123 <br /> sAN <br /> ENVIRUfNpC�UN7y <br /> HATH O PART 1E, <br /> ACCEPTEDBY: i EMPLOYEE#: DATE: J3�3 <br /> ASSIGNED TO: m s EMPLOYEE#: S DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: SoZ 3 P/E: a 03 <br /> Fee Amount: 3/a Amount Pa' 3�2 Payment Date 1 r3 3 <br /> Payment Type Invoice# Check# D eceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />