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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> tSl� (?U�le 35(o <br /> OWNER/OPERATOR <br /> Mike Frasinetti, HD Supply White Cap CHECK If BILLING ADDRESSE] <br /> FACILITY NAME HD Supply White Cap <br /> SITE ADDRESS 3601 N. Navone Rd. Stockton 95215 <br /> Street Number D6—._ Street Name Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1695 Eureka Rd. <br /> Street Number Street Name <br /> CITY Roseville CA STATE ZIP 95661 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (916) 751-2356 1 101-290-08 PA-1600122 (SA) <br /> PHONE#2 En.. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME Or MAILING ADDRESS FAx# <br /> 407 W. Oak St. (209 )369-0377 <br /> CITY Lodi STATE CA Z'P 95240 <br /> BILLING ACKNOWLEDGEMENT: I, 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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATTEp�and FAD laws. 11,^, <br /> APPLICANT'S SIGNATURE: /0/,4A DATE: L4 <br /> /Z 2— I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT IV1 CO/dSVLYArVT <br /> If APPLICANT 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 to the SAN JOAQUfN 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 OFSERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study MF <br /> COMMENTS: II Eo <br /> V <br /> n 4 0 >�� �4( a I ) SqN ogQu 2 2016 <br /> `v M NT <br /> ACCEPTED BY: km M��n � EMPLOYEE#: DATE: <br /> ASSIGNEDTO: LSW EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: S6 y2:5 PIE: ?UO2- <br /> FeeAmount: Amount Pai �95,DD Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />