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S tt f/ SERVICE REQUEST <br /> Type of Bu mess or Property P,4_6S6 u 7'/� FACILITY ID# SERVICE RE/QUEST# <br /> OWNER/OPERATOR Don Litchfield, Copperford LLC CHECK If BILLING ADDRESS® <br /> FACILITY NAME Vino Piazza <br /> SITE ADDRESS 12470 E. Locke Road <br /> Street Number D Street Name Lockeford 95240 <br /> CI ZI CUE <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Nama <br /> CITY STATE ZIP <br /> PHONE#f fir. APN# LAND USE APPLICATION# <br /> ( 209)727-9770 051-320-09 PA-05-744 (SA) <br /> PHONE#2 En. BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr <br /> Neil O. Anderson & Associates InC. 209 367-3701 <br /> HOME Or MAILING ADDRESS FAX# <br /> 902 Industrial Way (209 )369-4228 <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 arydlhat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and E ERAL laws (, <br /> APPLICANT'S SIGNATUIRRI / DATE: y// /1 1G <br /> PROPERTY/BUSINESS OWNERI� OPERATOR/MANAGER ❑ CVHER AUTHORIZED AGENT 13 <br /> IjAPPLICANT 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 t0 the SAN JOAQUIN 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 SERVICEREDUESTED: Review Nitrate Loading Study Update f'AYMEN7 <br /> COMMENTS: 51<-i D <br /> 6� ^^ ZD APR 1 9 2006 <br /> To Cri �J`✓y�� iP7�. ;:/%., �•fi SAN JOAQUIN COUNTY <br /> EVIRON-�---'�� NTAL <br /> HEALTH DE ARTME <br /> NT <br /> APPROVED BY: G l Li 1 L EMPLOYEE#: v ?-� / DATE: 4 !G <br /> ASSIGNEDTO: M �/3 -4 EMPLOYEE#: S3 E,�- DATE ( <br /> Date Service Completed (if already completed): SERVICE CODE ��.j P i E: <br /> Fee Amount L.( b5. o-L) Amount Paid Ly b s w Payment Date - � �L <br /> Payment Type ��' Invoice# Check# b S 3 Received By: 1� C' <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />