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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sr' 001 <br /> OWNER/OPERATOR <br /> Betty Galli CHECK If BILLING ADDRESS X <br /> FACILITY NAME Galli Property <br /> SITE ADDRESS 12601 W. Platti Rd. Tracy 95304 <br /> Street Number Direction I Street Name I Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 12650 W. Platti Rd. <br /> Street Number Street Name <br /> CITY Tracy STATE CA z'P 95304 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 836-4046 212-100-03 <br /> PHONE#I EXT. BOS DISTRICT LOCATION CO� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak Geo Environmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE CA z'P 95240 <br /> BILLING ACKNOWLEDGEMENT: I, 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 FE/SERA WS. <br /> APPLICANT'S SIGNATURE: l DATE: 1 / _2-0 <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT M C e"J1✓'--err-/T <br /> If APPL/CANT 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 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. <br /> TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report R ANT <br /> COMMENTS: RAR <br /> JI, D <br /> /o R �� 2020 <br /> AQU/N <br /> 4th ytH,l <br /> H <br /> ACCEPTED BY: C EMPLOYEE#: DATE: F—Q Z <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 523 P I E: - <br /> Fee Amount: L Amount Paid 36 �� Payment Date <br /> Payment Type o 0 Invoice# Check# Rec Ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />