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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVIAiOE E�QUEST <br /> Type of Business or PropertyFACILITY ID# SERVICE REQUEST# <br /> e <br /> OWNER I OPERATOR Cosentino WineryFECS 2 2 2006 CHECK if81LLINGADDRESS <br /> ® <br /> FACILITY NAME Cosentino Winery <br /> SITE ADDRESS3I.iY16.Y+�la vy � �� uu ate. <br /> 11715 N. Clements Road Linden 95236 <br /> Street Number Direction Street Name Ci Zi Cade <br /> HOME or MAILING ADDRESS of Different from Site Address) <br /> c/o David Lagorio, Diede ConstryF. P.O. Bax 1007 <br /> reumber Street Name <br /> CITY Woodbridge STATE CA zip 5258 <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> (209)369-8255 065-140-04 PA-05-794 <br /> PHONE#Y ExT• 13OS DISTR16T LOCATION CODE_) " <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAx# <br /> 902 Industrial Way 12091369-4228 <br /> i CITY Lodi STATE CA ZIP 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 /> I. COUNTY Ordinance Codes,Standar ,dsSTAT nd FEDERAL laws <br /> i APPLICANT'S SIGNATURE: —` &&�6 ] <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER © OTHER AUTHORIZED AGENT FM � 1Cj' <br /> 1 - If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> I <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 s it is available and at the came tme it is <br /> provided to me or my representative. g �� 2, �u <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study �� AYMEI�IT <br /> CDMME TS: @%&� jQE� Q� /v1 11771�T2[��1� r e,-�(v, FEB. 2' 6 <br /> SAN JOA IN COUNTY <br /> � •Q w � /Hyl �S/�� VIRO MENTAL <br /> H PARTMENT <br /> APP116VEDt3Y <br /> YEE rX_. E: � <br /> I ASSIGNED TO P-t 4 f!1 A � 'a >��,�, EMPLOYEE# �� `���lA DATE. �' <br /> Date Service Completed {if already completed) xh ' SERVIcL.Coa P 1 E : <br /> _ rx <br /> F, P a .: .. <br /> Fee Amount 5 o v Amount Paid Payment Date 2 <br /> i Payment Type t f Invoice# Check# t -3 3 Received By. <br /> r <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> E - <br />