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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5.277140 6 <br /> OWNER/OPERATOR <br /> Ed Chitwood CHECK IF BILLING AODRESSE1 <br /> FACILITY NAME Chitwood Property <br /> SIrE4 ?D9s ss4825 <br /> Horner Ave. Stockton c15745 <br /> 4 <br /> S{reet831 E Number I Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 1700 Lodi Ave. <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Lodi CA 95242 <br /> PHONE#I E�' APN# LAND USE APPLICATION# <br /> (209) 625-8394 159-070-39 /11 _ �-- /2�; <br /> PHONE#2 E><r• BOB DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ' <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME Or MAULING ADDRESS FAz# <br /> 407 W. Oak St. (209)369-0377 <br /> CITY Lodi STATE CA z"'95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 FED lay s. <br /> APPLICANT'S SIGNATURE: DATE: 5 <br /> PROPERTY/BUSINESS OWNER TOR/MANAGER ❑ OTHER AOTHORIZED AGENT[3 <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 enviromnental/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. ftA. <br /> fir. <br /> TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report C <br /> coMMENTs: Mar 88 <br /> Fo <br /> y61CTy0E 4 7�N)y <br /> ACCEPTED BY: MGP{'DJf;t4n EMPLOYEEM DATE: 5✓f0- 0 <br /> ASSIGNED TO: EMPLOYEEM DATE: ri—li-17 <br /> Date Service Completed (if already completed): MICE CODE: 17-13 P 1 E: �(ya3 <br /> Fee Amount: Amount Pa -Q-7T-ZD, Payment Date (5/F/17 <br /> Payment Type Invoice# Check# �S�7 Rec ived By: alp <br /> EHD 4&02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />