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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SI`6b 7953 � <br /> OWNER/OPERATOR <br /> Janet Willett/Ronald Benedix CHECK if BILLING ADDRESS <br /> FACILITY NAME Willett/Benedix Property <br /> SITE ADDRESS 26050 E. Edwards Ave. Escalon 95320 <br /> Street Number Dim' a I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (N Different from Site Address) same <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (209) 838-8962 207-320-09 <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> c ) Ci <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK it BILLING ADDRESS <br /> BUSINESS NAME PHONE# En. <br /> Live Oak GeoEnviron mental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> 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 DEPARTNIEvT 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 JOAQtTN <br /> CouNTY Ordinance Codes,Standards, ' TE and FEDERAL laws. <br /> A <br /> APPLICANT'S SIGNATURE: DATE_ 412 4j ZZ <br /> PROPERTY/BUSINESS OWNE40N OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tate <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 JoAQum COuNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study PAYMENT <br /> COMMENTS: RECEIVED <br /> AUG 2 0 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: T' EMPLOYEE#: DATE: Z0, )VI <br /> ASSIGNED TO: I l v1 EMPLOYEE M DATE: �. ZC1 l� <br /> Date Service Completed (H already completed): SERVICE CODE: z PIE: <br /> Fee Amount: Amount Paid 3o4, av Payment Date 20 1 p <br /> Payment Type C(� Invoice# Cheek# 3y SS Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />