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SAN JOAQ-_1,;COUNTY ENVIRONMENTAL REAL_ -DEPART!��0 O 0 6 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Single Family Residential S`K M`93S 1- <br /> OWNER/OPERATOR U <br /> Pock Lane Partners, LLC. CHECK if BILLINGADORESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS 2706 Pock Lane TStockton 95205 <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 119 S[reetNumber E Weber AvgpgAame <br /> CITY STATE ZIP <br /> c,-- _ - - J52,02 , <br /> PHONE#1 939-9025 APN# LAND USE APPLICATION# <br /> (209 ) 17q-120-13&14 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( 1 J <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAN}Sock Lane Partners, LLC. PHONE#) (209) 939-9025 ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> 119 E Weber Avenue ( ) <br /> CITY Stockton STATE CA ZIP 95202 <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 and FED aws. _ <br /> APPLICANT'S SIGNATURE: DATE: ` Z� <br /> PROPERTY/BusiNESs OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑_�Cl'�45'!47 Gr'l 'z - <br /> IfAPPLICANT is 7 2 o t theBILLINGP_4R77,,proof of authorisation 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 aoIdiC i is <br /> provided to me or my representative. ��li <br /> TYPE OF SERVICE REQUESTED: Surface and Subsurface Contamination Report <br /> COMMENTS:6n'),' ed Q,., APP 0 6 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: T�Zlz_ EMPLOYEE <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 (� Payment Date n� l <br /> Payment Type 10 Invoice# Check# Received By: �A1/// <br /> v <br /> EHD 48-02-025 1 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />