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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ::I S( 0Cff9 ( <br /> OWNER/ OPERATOR <br /> L.A. Delta Investments, Inc. CHECK If BILLING ADDRESS <br /> FACILITY NAME Lockewood Stables <br /> SITE ADDRESS 20703 N' Elliott Rd. Lockeford 95237 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number P.O. Box 1040 Street Name <br /> CITY Lockeford STATE CA ZIP 95237 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (714 ) 403-4254 051-210-71 & -72 PA-1700268 (UP) <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Abby Racco <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EaT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE CA ZIP95240 <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 ENVIRONNfFNTAL 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 an ORAL laws. <br /> APPLICANT'S SIGNATURE: g )I� DATE: <br /> PROPERTY/BUSINESS OWNER O RA R/ AGER 11 OTHER AUTHORIZED AGENT L1 <br /> If APPLICANT is not the ILL/ PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE RMATION: When applicable, 1,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 ENviRoNNiENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. p <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study ww//11F <br /> COMMENTS: 40, I O <br /> 0 lyai a -8S S N ry7 <br /> ACCEPTED BY: EMPLOYEE#: DATE: I V <br /> ASSIGNED TO: to 1 EMPLOYEE#: DATE: <br /> Date Service Comple d (if already completed): SERVICE CODE: c Z 2 1 P1 E: 2 � <br /> Fee Amount: �� ` '— Amount Paie o v Payment Date <br /> Payment TypeYL/ Invoice# Check# Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />