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I In �. <br /> 1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUE&sT <br /> Type of Business or properly Y <br /> FACILITY ID# <br /> J Winery SERVICE REQUEST# / <br /> OWNER/OPERATOR 4-M 7IP <br /> Tim Holdener <br /> FACIDTY NAME CHECK If BILUNG ADDRESS® <br /> Macchia <br /> SITE ADDRESS 7099 <br /> E' <br /> tr Peltier <br /> atNumbar „ Acampo 95220 <br /> HOME or MAILING ADDRESS Of Different tram Site Address) ( i <br /> CITY beat Nu bar <br /> e N <br /> STATE ZIP <br /> PHONE in En. APN# t <br /> ( 209) 333-2600 005-260-42 LAND USE APPLICATION# <br /> OQ g <br /> PHONE#2 Ext � <br /> I I BOS DISTRICT (((Y /- LOCATION CO <br /> Qg <br /> REDUESTOR <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> eylm <br /> BUSINESS NAME Nancy Rosulek <br /> CHECK If BIWI NG ADq(ysS❑ <br /> Neil O. Anderson & Associates Inc. PHONE# Em <br /> HOME or MAIuNG ADDRESS 209 367-3701 <br /> 902 Industrial Wa FAx# <br /> CITY (209)369-4228 <br /> Lodi STATE CA <br /> BILLING A KNpTy e 'ri AA ZIP 95240 <br /> acknowledge that all site and/or projectC specific ENVIRONMENTAL HEALTH DEP1, the undersigned property or ARTMENT hourly Charges assoated with s owner, Operator or authored tthis 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,SlondardS,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: —2? <br /> _ )/ <br /> PROPERTY/BUS-INES$OWt� `nJ ! 'DATE: /G -> <br /> NER + <br /> 4+/ OPPI(ATOR/MANAC 13OTHER AUTHoHHzFn-J0 VT❑ <br /> {VAPPLICANT is not the BILLING PARTYroo of aHtJro[i>r" Cj <br /> t <br /> AUTHOR IZATION TO RELEASE INFORMATIO`' f"T �SI d Title <br /> above —c address, hereby authorize the release of ad /t� p� ?d Title <br /> of the property located at the <br /> information l0 the SAN JOAQUIN COUNTY ENVIRONMENT,., ;�y^Y�/y�1, and/or environmental/site assessment <br /> provided to me or my representative. jGf is available and at the same time it is <br /> TYPE OF SERVICE REQUESTED: yA/�M' <br /> ', CouMENTs: Soil Suitability Nitrate Loading Study `y <br /> 18 2007 <br /> APPROVED BY: ` SAN JOAQUIN COUNTY <br /> EMPLOYEE#: T <br /> HD 'IrA1Ef' <br /> 1 ASSIGNED 70: <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (n already completed): <br /> SERVICE CODE: 7- PIE: <br /> 'as Amount: . O Amount Paid p0 <br /> Payment Date l� O <br /> _ �'yment Type V � Invoice# Check# <br /> 11 s L 7 Receive By: <br /> 'A8-01.025 <br /> F ED 6-5-02 - SERVICE REQUEST FORM <br />