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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER i OPERATOR James Gwerder CHECK If BILLING ADDRESS FACILITY NAME Lehman Road Property SITE ADDRESS 28801S. Lehman Rd. Tracy Street Number DIS I.— Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 11847 W. Valpico Rd. Street Number Street Name CITY Tracy STATE CA zip 95376 PHONE#1 EaT. APN# LAND USE APPLICATION# (209) 483-1298 253-330-33 V P 16 0 a.�-65 Mss PHONE#2 EMT. BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR Abby Rocco CHECK if BILLING ADDRESS BUSINESS NAME PHONE# EXT. Live Oak GeoEnvironmental 209 369-0375 HOME Or MAILING ADDRESS 407 W. Oak St. (209 )369-0377 CITY Lodi STATE CA zIP95240 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge 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. 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 COUNTY Ordinance Codes,Standards,STATE and FEDERAL lot s. APPLICANT'S SIGNATURE: V.A .C,N-P/(4� DATE: 0- (7- (6 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENTpf Afftic� IfAPPLtCANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. PAYMENT TYPE OF SERVICE REQUESTED: Review Soil Suitability Study CE1VE© q p ;1 COMMENTS: ,, V 2 2 2016 19/16 Qt^'t�"�o r"1� SAN JOAQUIN COUNTYEINVIROMENTAL i HEALTH DEPARTMENT ACCEPTED BY: % - rn EMPLOYEE M DATE: ASSIGNED TO`-� EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: Fee Amount: 9Amount Pal X78 (� Payment Date Payment Type Invoice# Check# l' Rece ved By EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003