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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER i OPERATOR <br /> Patricia Van Groningen CHECK if BILLING ADDRESS <br /> FACILITY NAME Van Groningen Property <br /> SITE ADDRESS 14141 E. Lone Tree Rd. Manteca 95336 <br /> Street Number DI I ntm.tName CRY Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 15176 Jack Tone Rd. <br /> Street NumberStreet Name <br /> CITY Manteca STATE CA ZIP 95336 <br /> PHONE#1 E"T. APNIt LAND USE APPLICATION# <br /> (209 ) 982-4349 203-050-10 <br /> PHONE#2 E,T• BOS DISTRICT LOCATION CODE <br /> ( ) 11 <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 FA%# <br /> 407 W. Oak St. <br /> (209)369-0377 <br /> CITY Lodi STATE CA Z"'95240 <br /> BILLING ACKNOWLEDGEMENT: L 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: /& /� DATE: �O Z4I <br /> I mr <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT pI 641,4.9JIYM.I� <br /> IfAPPLLCANT 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 JOAQUrN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is 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 <br /> COMMENTS: <br /> 6�a� l <br /> rn✓ <br /> ACCEPTED BY: //' EMPLOYEE#: DATE: <br /> ASSIGNEDTO: ! �1 EMPLOYEEM DATE: <br /> Date Service Completed (B already completed): SERVICE CODE: 3 PIE: <br /> Fee Amount: 000 Amount Paid a d C, co Q Payment Date C9 �l7 <br /> Payment �e. Invoice# Check# Received By:EHD 48-02-0 <br /> IJAYMLNIF <br /> REVISED 11/171200325 <br /> /217/2003 RECEJ fMoIden Rod) <br /> JUN 2 6 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br />