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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# A 'o OWNER/OPERATOR Amar Mathfallu CHECK if BILLING ADDRESS FACILITY NAME Ash & Veer Enterprises Property SITE AD- N. Hiahwav 99 W. Frontaqe Rd. Acam o _� 18915 p Ti20 Street Number Di c Str t N m Zi Code HOME Or MAILING ADDRESS (If Different from Site Address) 18915 N. Highway 99 W. Frontage Rd. Street Number Street Nam CITY Acampo STATE CA ZIP 95220 PHONE#1 ExT. APN# LAND USE APPLICATION# (209 ) 481-2627 013-220-16 rA H oo 7- �l S PHONE#2 ExT. BOS DISTRICTOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR Abby Racco CHECK If BILLING ADDRESS BUSINESS NAME PHONE# EXT. Live Oak GeoEnvironmental 209 369-0375 HOME or MAILING ADDRESS FAX# 407 W. Oak St. (209 )369-0377 CITY Lodi STATE CA Z'P 95240 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,StandardsXSd FEDF_ laws. APPLICANT'S SIGNATURE: DATE: 11-20-14 PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 11OTHER AUTHORIZED AGENT consultant f f APPLIG9NT it not the BILLING PARTY,proof of authorization to sign is required Time AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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. TYPE of SERVICE REQUESTED: Review Surface & Subsurface Contamination Report RECEIVED COMMENTS: 14 k NOV 2 1 2'017 UJt-'r c"Wl"-y SAN JOAQUIN COUNITN ENVIROMENTAL HEALTH DEPARTMENT ACCEPTED BY: - /V �� EMPLOYEE#: DATE: If 2//1 ASSIGNED TO: ��jLQ�� / EMPLOYEE#: S/ DATE: �� 2,1114 Date Service Completed (if already completed): SERVICE CODE: 315- P 1 E: 26c)-3 Fee Amount: 2(p 1*) — Amount Paid Payment Date 'X' Payment Type Invoice# Check# Receive By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003