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SAN JOAQUIN Cow T,Y,Y E <br />-SER <br />Type of Business or Property FACILITY ID# SERVICE REQUEST# SQoo i L\ -2-=rL, <br />OWNER I OPERATOR Eugene Marsili CHECK if BILLING ADDRESS [El <br />FAc1urv NAME Marsili Property <br />SITE ADDRESS3212 & 3225 E. Street Number Direction <br />Woodson Rd. <br />Street Name <br />HOME or MAILING ADDRESS (If Different from Site Address) 377 <br />CITY Acam o <br />PHONE #1 ( 209 l 403-7373 <br />PHONE#2 <br />( ) <br />Street Number <br />EXT. APN # <br />005-145-31 & -49 <br />EXT. <br />Acampo <br />Cit <br />Rode Rd. Street Name STATE ZIP CA <br />LAND Use APPLICATION# <br />BOS DISTRICT l I <br />CONTRACTOR I SERVICE REQUESTOR <br />95220 <br />Zi Code <br />95220 <br />LOCATION CODE ac; <br />REQUESTOR bb R A y acco CHECK if BILLING ADDRESS □ <br />BUSINESS NAME . PHONE# EXT.; <br />Live Oak Ge0Env1ronmental <br />HOME or MAILING ADDRESS 407 W. Oak St. <br />CITY Lodi <br />(209 l 369-0375 <br />FAX# <br />( STATE CA <br />) <br />ZIP 95240 <br />·• <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowiedge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project 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 perfo1med will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'SSIGNATURE: � � �-DATE: C).-;;J,2-2/ <br />PROPERTY / BUSINESS OWNER ii� z-ANAGER O OTHER AUTHORIZED AGENT 0 ----------- <br />r r 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 s'ite address, hereby authorize the release of any and all results, geotechnical data and/or enviromnental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at��� tin;ie it is <br />provided to me or my representative. 1 IV/IE, <br />TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report <br />COMMENTS: <br />ACCEPTED BY: <br />ASSIGNED TO: FR. <br />Date Service Completed (if already completed): <br />Fee Am.aunt� {S --S-.:/1/ Amount Paid <br />Payme�t Type Invoice# <br />EHD 48-02-025 REVISED 11/17/2003 <br />EMPLOYEE#: q I J, 7 /41 J <br />EMPLOYEE#: <br />SERVICE CODE: �-J 5 <br />'30L( .-Payment Date <br />Check# )-\ '() 3-=(- <br />p / E: d, f,O '3- <br />Received By: <br />SR FORM (Gol4n Rod)