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SAN JOAQUIN COUNTY EYVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACLRYDO SERVICE REQUEST <br /> c1{ZUUY1 <br /> OWNER OPERATOR Roddan Family Trust c„tEca jt tNi��^•^^^-'^^� <br /> FAcutT NMR Roddan Property <br /> Slit AmDRZ3585&236 9 S. Manteca Rd. Manteca 95337 <br /> 4,Cask <br /> HOME OF MAILING ADDRESS (If DiMvrvnHrom Site Addreaal 23601 S. Manteca Rd. <br /> Cm Manteca STATE CA ZIP 95337 <br /> PHONE MIE•'' APNk LAID USE MPUCATIONS <br /> 12091 610-8042 226-110-35 &-36 PA-1600231 <br /> pNt11E N2 E"' MOS OSTRICT Lou M <br /> ____._..._..___------ _._____.-______ ___.____.....- <br /> CONTRACTOR i SERVICE REQUESTOR <br /> REOUESTOR <br /> Abby Racce utKaReulraealdoEaEO <br /> Bus*ess NAME PHONE* Ee'. <br /> Live Oak GeoEnwronmental 1209)369-0375 <br /> HOME or MAILING ADDRESS Pull <br /> 407 W. Oak SL <br /> cm_ Lodi STATE CA zr95240 <br /> RII uN:AC KNQWj DClZMK T 1, the undersigned proper uI business owner.Operator of authorised aVrnt of same. <br /> acknowledge that all ate and/or project Specific ENVIRONMENEAL HEALn1 DLPARILDnNI be arly charges associated with this prujtel <br /> or activity will be billed to me Or my bashers as identified On this fomf. <br /> 1 also certify'that I have p jeued Iii pphcation and t fol the sora h tO be MfOMWJ Will bi.last in 2"Wdatwc With all SAN JO,"ILN <br /> CUI NTY Ordosame Gales,Stand/aft g I FI l 7 AL 1 <br /> APPLICANT'S SIGNATUyR�Ep7 LJv D.rt L: <br /> P¢urE¢iTl RLsrNESs OatNEal]I C OKUTnn l MAbACER ❑ t1111Ul Arloonl/.tLALtSr❑ <br /> If ilri91t r'.1 is ant etre BD uvt;PARTI.RN'rMf elfNNrllwization r0 4,it IS reruired rid, <br /> Al 1 HORI \110\ III RELEASE INFORDIATIONi When applicable.1,the owner or operator Of the property located401 <br /> fne 1dJrret. :!,y au[Imnsv the release of any and all results, geotechnical data af,d'Or envuonlrwntal site as 's <br /> I,[hc )A\J{MUCIN CULNIY'ENVIRU,•'f N I:%L HEATH DEPARDALNT as seen as it la assiloble and al the ralfe tinprovukd t raw or my representative. vF T <br /> T'IPEOFSERNOLREOIJESTED: Review Sal Suitability Study <br /> COU <br /> SAN <br /> 7r G ���7 y�cry�N E"7,14"'Y <br /> 6o M<�(/ 36 Mit MFNr <br /> AncEPrEo BT: / EMrLorff P: DATE: <br /> ASSIGNED TO: DATE; <br /> Dale Service C mplet" (if V.Sdycumpleleal: HHNICECOOE: PIE <br /> 3 FeeAmoUM: V __ Ameunt Paleo 'w I Paytnertage 7� <br /> Payment Typ Invoice Is Check P Sd By. <br /> Fi10 4&04,075 SR FORM(GOIdan Rod) <br /> REVISED 1111717003 <br />