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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S �oo7��y� <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> Delicato Family Vineyards/San Bernabe Vineyards, LLC <br /> FACILITY NAME Delicato Family Vineyards <br /> SITEADDR s S. Highway 99 W. Frontage Rd. Manteca 95336 <br /> ' 001 & 12165 <br /> Street Number Direction tree[Name vu ZIP Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 12001 S. Highway 99 W. Frontage Rd. <br /> Street Number Street Name <br /> CITY Manteca STATE CA ZIP 95336 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 824-3600 <br /> 204-050-49 etc. PA-1300032 <br /> PHONE#2 EXT. JBOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# En. <br /> Live Oak GeoEnvironmental 209 369-0375 ! <br /> HOME or MAILING ADDRESS FAx# <br /> 407 W. Oak St. (209)369-037 <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 /> also certify that l 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 SIGNATUATE: <br /> MlPROPERTY/BUSINESS OWNER Co I i <br /> OTHER AUTHORIZED AGENT❑ <br /> IrAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Titfe <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 to 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study RECEIVED <br /> COMMENTS: 61911-7 vt� c '�p �1'��� '7 �l -t^l_ �(•Q.(� jUN <br /> ��j /�j fr�'A , & /l/ /,.' l��y (� SAENVIRO ENVIRONMENTAL/0 1I/ / /t ENVIRONMENTAL <br /> QQ,U/ HEALTH DEPARTMENT <br /> ACCEPTED BY: A�nt/g4,IL <br /> II/'(' a. EMPLOYEE#: DATE: <br /> ASSIGNED TO: TQ I (�SIO O U l V C EMPLOYEE#: DATE: U' <br /> Date Service Completed (ii already completed): SERVICE CODE: ' PIE: , b ;,2— <br /> , c _ . <br /> L <br /> Fee Amount: unt Pal Payment Date j <br /> - <br /> Payment Type CSL Invoice# Check# Received By: ? <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />