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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> cJ� 00'�Iq <br /> OWNER/OPERATOR <br /> Matt Shinn CHECK If BILLING ADDRESS <br /> FACILITY NAME Block 21 Winery <br /> SITE ADDRESS 21600 N. Davis Rd. Lodi 95242 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 21 770 N. Davis Rd. <br /> Street Number Street Name <br /> CITY Lodi STATE CA Zip 95242 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (209) 483-1228 013-080-43 PA-1800093 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 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 /> ( ) <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,STA — FEDERAL laws. <br /> APPLICANT'S SIGNAT� DATE:_/S�� <br /> PROPERTY/BUSINESS OwNER PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 atak same time it is <br /> provided to me or my representative. 19 y <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study V <br /> COMMENTS: <br /> Jo <br /> CO <br /> STM NT <br /> ACCEPTED BY: EMPLOYEE#: L-1111G DATE: // 7/1 <br /> ASSIGNED TO: U.,^ EMPLOYEE#: DATE: <br /> Date Service Completed (i (ready comple d): SERVICE CODE: P 1 E. U <br /> Fee Amount: d Amount Pai ��� �- Payment Date 1 1 <br /> Payment Type ,� Invoice# Check# Ij Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />