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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 0- <br /> Winery <br /> Winery FACILITY ID# SERVICE REQUEST <br /> OWNER/OPERATORI��JCJ'�I..JE <br /> + Tim Holdener x CHECK if 8ILiING gofl�ESS® <br /> FACILITY NAME <br /> Macchia <br /> SITE ADDRESS 7098 <br /> Street Number D,rE�;o„ Peltier Acam a <br /> F HOME or MAILING ADDRESS (If Different from Site gddressJ Street Mame 1} 95220 <br /> C Zi Code <br /> CITY Street Namber <br /> Street Name <br /> STATE ZIP <br /> PHONE#1 ExT• APN# 1 <br /> ( 209) 333-2600 005-260-42 LAND USE APPLICATION# <br /> g.PHONE#2 ExT 00� <br /> ( 1 B05 DISTRICT ,/ LOCATION Co <br /> REQUESTOR CONTRACTOR/ SERVICE REQUESTOR C� <br /> Nancy Rosulelc <br /> CHECK if BILLING..r;,sS b <br /> BUSINESS NAME <br /> Neil O. Anderson & Associates Inc. PHONE ExT. <br /> HOME or MAILING ADDRESS 209 367-3701 <br /> 902 Industrial Wa FAx# <br /> CITY 1209 )369-422$ <br /> Lodi STATE <br /> BILLING ACKNOWLEDGEMENT: i, the undersigned pro aowner, CA ZIP 95240 <br /> acknowledge that all site and/or project specific ENVIRONMENTAL H ALTH DEPARTMENT hourly charges associated withtthis projecoperator or authorized agef t <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> I tDATE: �G _ <br /> PROPERTY/BUSINESS OWNER OPERATOR/NIANACER ❑ <br /> OTHER AIITHORI7F_n ❑ <br /> fAPPLICAA'T is not the BILLINGpQR7y proof of authorr'.!n-e <br /> AUTHORIZATION TO RELEASE INFORMATI ' <br /> J�/a5/�j'd Title <br /> OE <br /> above site address, hereby authorize the release of at.. /11 � J 'perator of the property located at the <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENT,. ,Jr� � and/or environmental/site assessment <br /> provided to me or my representative. i is available and at the same time it is <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Naar' <br /> Soil Suitability Nitrate LoadingStud �-, <br /> 4 <br /> 18 2007 <br /> t SAN JOAQUIN COUNTY <br /> APPROVED 6Y: / TAL <br /> ASSIGNED TO: <br /> EMPLOYEE : TH DE <br /> 1 � <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: <br /> 'ePIE: <br /> e Amount: . v" 1i <br /> x .E Q, Amount Paid Payment Date <br /> �yment Type l/ Invoice# t� <br /> 4� Check# 7 Received By: <br /> X48-09-025 <br /> SED 6-5-62 SERVICE REQUEST FORM <br /> } <br />