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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN71EFAAA'LIED <br /> SERVICE REQUEST IL2LZ7 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SMS-i as <br /> OWNER/OPERATOR <br /> Richard Teicheira et al. CHECK If BILLING ADDRESS <br /> FACILITY NAME Teicheira Property <br /> SITE ADDRESS 6721 E. Perrin Rd. 8t 24500 S. Union Rd. Manteca 95337 <br /> Street Number Direction I Street Norm I city <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6191 E. Perrin Rd. <br /> Street Number Street Name <br /> CITY Manteca STATE CA 7JP 95337 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 608-4286 1257-130-02 8t-10 <br /> PHONE#2 ExT• BOS DISTRICT LoCAnQNQPDE <br /> ( ) 9 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADORESM <br /> BUSINESS NAME PHONE# EhTZT <br /> Live Oak GeoEnvironmental 209 369-0375 E�VF� <br /> HOME or MAILING ADDRESS FAX# A UG <br /> 407 W. Oak St. ( ) 4 2023 <br /> CITY STATE LP E Q QU <br /> Lodi CA 952 Nv/ N <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent o ENO CNT y <br /> acknowledge that all site and/or project specific ENVMONME\TAL HEALTH DEPARTMENT hourly charges associated with this project RrMEN7- <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 FEDERAL I s. <br /> APPLICANT'S SIGNATURE: DATE: --2 -2 3 <br /> PROPERTY/BusmEss OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Liii C-odN yVL:rjj T <br /> If APPLicANT is not the BJLL/NG 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 environmental/site assessment <br /> information to the SAN JOAQUIN CouNTY ENvIRONMEN"rAL 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 /> COWIENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �11�� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: X� Z? P 1 E: Q3 <br /> Fee Amount: Amount Paid 3��;� Payment Date L 2- ,)3 <br /> Payment Type Invoice# Check# 16774'T01=Recelved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />