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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> Norman Gene Norton CHECK if BILLING ADDRESS <br /> FACILITY NAME Norton Property <br /> SITEAIt1200 18350 S. Henry Rd. Escalon 95320 <br /> I O S et Number Direction Street Name CitV Zip Code <br /> HOME or DDRESS (If Different from Site Address) P.O. BOX 1 024 <br /> Street Number ,,,rest Name <br /> CIN STATE ZIP <br /> Wri htwood CA 92397 <br /> PHONE#1 EXT. AP LAND USE APPLICATION# <br /> 1760 ) 442-6944 229-260-27 30 <br /> PHONE R EXT. BOS DISTRIC_l LOCATION CODE <br /> ( fflo 4 �11 C,9 d <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EZT. <br /> Live Oak Geo Environmental 209 369-0375 <br /> HOME Or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �rF�J�G� J DATE <br /> :: .3 '2i <br /> PROPERTY/BUSINESS OWNER 13 OPER/TOR/MANAGER ❑ OTHER AUTHORIZED AGEN7J <br /> If APPLICANT is not the BILLING PAR rI'proof of authorization to sign is requirQ/d\ 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 t}if;,same time it is <br /> provided to me or my representative. 011 tlftli­ <br /> TYPEPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report 114fCe/ <br /> COMMENTS: <br /> R 12018 <br /> OAQU1Af <br /> N�C>�0E 7,'4L <br /> ACCEPTED BY: 'l// EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paif t3oy Da Payment Date 34l <br /> Payment Type Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />