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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#/ <br /> ,5r- 00 7 r% V7l, <br /> OWNER/OPERATOR <br /> Parbati Chand c/o Arun Malik & Anila Prasad CHECK if BILLING ADDRESS El <br /> FACILITY NAME Parbati Chand Property <br /> SITE ADDRESS 3510 1 E. Guernsey Ave. Stockton <br /> 95205 <br /> Street Number Direction Street Name Cit Zio 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 /> (714) 318-3032 157-140-32 <br /> PHONE#2 EXT. BOS DISTRICT1 LOCATION CODE <br /> ( ) C' C G <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak Geo Environmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAx# <br /> 407 W. Oak St. <br /> (209 )369-0377 <br /> CITY Lodi 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, TATE and FEDERA I WS. <br /> APPLICANT'S SIGNATURE: A4 Aiee DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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. c <br /> TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report <br /> COMMENTS: �® <br /> 2 <br /> %,to Sip 12418 <br /> h FNV/R Q�tN C <br /> B'gCTy Fp�HTIJAI I-' <br /> MF <br /> ACCEPTED BY: EMPLOYEE#: DATE: e-7� J <br /> c l <br /> ASSIGNED TO: '1��r-�; EMPLOYEE#: DATE: 2- y / <br /> Date Service Completed (if already completed): SERVICE CODE: Z� P 1 E: <br /> Fee Amount: Amount Pa' 301 Payment Date q <br /> Payment Type Invoice# Check# ! Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />