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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S�L.Op15551 <br /> OWNER/OPERATOR <br /> Craig & Sheri Watts CHECK If BILLING ADDRESS <br /> FACILITY NAME Watts Property <br /> SITE ADDRESS 16400 N. Linn Rd. Lodi <br /> Street Number Street Name city Zip Co e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> StreetNumber P.O. Box 474Street Name <br /> CITY Victor STATE CA ZIP 95253 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION It <br /> (209 ) 368-2974 1 053-110-04 ZO <br /> PHONE#2 EXi. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAx# <br /> 407 W. Oak St. (209 )369-0377 <br /> CITY Lodi STATE CA ZIP95240 <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 /> 1 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, ST4,TFand FEDERAL laws. O /- <br /> APPLICANT'S SIGNATURE: za/ /`R DATE: o ZZ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT I® CMSvt,T-AArT <br /> 1f APPLICANT is not the BILLING PARTY proof of authorization t0 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it i5 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 PAYIII <br /> COMMENTS: '3//5 A. %//f(/j. ECI <br /> PZ�1712-v n AU' 222016 <br /> 464EV'AQ0 <br /> ACCEPTED BY: 11 EMPLOYEE#: DATE: <br /> ASSIGNED TO: r EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �� P 1 E: <br /> Fee Amount: 7-39 .V. Amount Paid a7�r4 0 1 <br /> Payment Date gu 6 <br /> Payment Type Invoice# Check# NSs-- I Received By:X <br /> 48-02-025 SR FORM(Golden Rod) <br /> ISED 11/17/2003 <br />