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SAN JOAQUIN COUNTY ENN"IRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST If <br /> X54 rll <br /> OWNER/OPERATOR <br /> GVG Investment Group (Tony Ghio) CHECK if BILLING ADORES s X <br /> FAGUTYNAME GVG Investment Group Property <br /> SITE ADDRESS 2321 1 Willow & 2320 E. Harding Stockton <br /> Street Number Direct Street Name Cdy Z.p Codc <br /> HOME or MAIUNG ADDRESS (ff Different from Site Address) 1 229 Rosemarie Ln. <br /> Street Number Street Name <br /> Gry Stockton STATE CA Z'P 85207 <br /> PHONE#1 EKr. APN N LAND USE APPLICATION U <br /> (209 ) 601-2991 141-194-18 X14-/�- 3 (/416) <br /> PHONE Irl EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REDUESTOR <br /> Abby Racco CHECK it BILLING ADDRE_ss0 <br /> BUSINESS NAME PHONE 0 Ea T. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAx# <br /> 407 W. Oak St. 1209►369-0377 <br /> CITY Lodi STATE CA Zip 95240 <br /> BILLING ACKNOWLEDGEMENT: 1. the undersigned property or business ossner, operator or authorized agent of same. <br /> acknowledge that all site and or project specific I_NVIRONMtiNTAI.IL'u.TII DEPART\11\T hourly charges associated with this project <br /> or activity will he hilled 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 /> COLNTY Ordinance(odes.Standards,SLATE and hL�DGRRAL laws. <br /> APPLICANT'S SIGNATURE: DATF: <br /> u <br /> PkrelttY/BtsmEssO%%,*4Lt❑ N ry <br /> OPt.iLNFO <br /> /MANAGER {2./ 01IIVR:4,t tNORITEDAclVTO <br /> If APPLICANT is not the BILLING 84671.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable. 1. the owner or operator of the property located at thr <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 COUNry ENVIRONMENTAL IIEALTH DEPARI-NIENT as soon as it is available and at the saBf►a. C it i, <br /> provided to me or my representative. A�E f T <br /> TYPE OF SEFMCE REQUESTED: Review Surface & Subsurface Contamination Report � <br /> COMMENTS: l l�1 <br /> AER-47 / � l rlcv.>- rv, -, SgN.10 32715 <br /> A Qtjllv CO IV <br /> EALTH pEAE T1 <br /> ACCEPTED BY: LCJ� EMPLOYEE#: DATE: L �S <br /> ASSIGNED TO: ASCO rrz) EMPLOYEE#: DATE: r3 u- <br /> Date Service Completed (if already completed): SERVICE CODE: 3 C P/E: 03 <br /> Fee Amount: Z -- Amount Paid a/_ U� Payment Date -;�- ,23 <br /> Payment Type L/ Invoice# Check# 3,53 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />