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SAN JOAQ ULN COUNTY ENVIRONMENTAL HEALTRME <br /> ,JEPARTNT. 1*21000 6 <br /> SERVICE REQUEST 1.021000 f_?' I <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Single Family Residential S2,bD 83S 1- <br /> OWNER/OPERATOR Pock Lane Partners, LLC. CHECK if BILLING ADDRESS❑ <br /> FAClurr NAME <br /> SITE ADDRESS 2706 Pock Lane Stockton 95205 <br /> Street Number Direction Street Name citv Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 119 Street Number E Weber Avg{?.WAame <br /> CITY STATE ZIP <br /> Stockton A 95202 <br /> PHONE#1 939-9025 ExT APN# LAND USE APPLICATION# <br /> (209 ) 174-120-13& 14 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NA"5ock Lane Partners, LLC. PHONE# (209) 939-9025 Exr. <br /> HOME Or MAILING ADDRESS FAx# <br /> 119 E Weber Avenue ( ) <br /> CITY Stockton STATE CA ZIP 95202 <br /> BIIIING 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 and FED aws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑_���ysj�7 �iliJ}��� <br /> If APPLICANT 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 a _.same�iQlS�.ltis <br /> provided to me or my representative. ���E�"," <br /> TYPE OF SERVICE REQUESTED: Surface and Subsurface Contamination Report <br /> COMMENTS:e APR 0 6 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> r <br /> ACCEPTED BY: :�!�L/z_ EMPLOYEE#: DATE: a, <br /> ASSIGNED TO: Q EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 523 P,�-2603 <br /> Fee Amount:$304.00 Amount Paid 3 0 Payment Date &�� <br /> Payment Type Invoice# Check# Received By: '� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />