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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> David & Corene Phillips Trust CHECKt BILDNGAODRE55E] <br /> J J S T <br /> FACILnYNAME Phillips Farms/Michael David Winery <br /> SITE ADDRESS 4580 W. Highway 12. Lodi 95242 <br /> re <br /> Stet Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 1128 6th Street ',J f J`l /'2— <br /> c/o <br /> c/o Elwyn Heinen, Advanced Design Group Street Number Street Name <br /> CITY Modesto !/ ( M.I <br /> M.I �2 <br /> STATE CA ZIP 95354)� <br /> PHGNE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 577-3108 1 055-160-50 & -29 PA-1300118 / BP-1703567 <br /> PHONE#2 Eta. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco <br /> CHECK if 81W NG ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( ) <br /> CITY Lodi STATE CA zIP 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 /> 1 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,STAT nd DERAL la / <br /> APPLICANT'S SIGNATURE: DATE: I <br /> PROPERTY/BUSYNESS OWNER❑ OPERATOR/MANAGER OTHERAUTHOR1zEDAGENT❑ <br /> IfAPP/./e4Nr is not the B/LL NG PARTY proo of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 /> rm <br /> infoation 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. P� <br /> TYPE OF SERVICE REQUESTED: Review Nitrate Loading Study Addendum IVASC <br /> COMMENTS: �1/ I /I / yT \ <br /> 1// /U�_`/�J �rn,�v �1/t¢.W £p S N�gQZ 8 <br /> EyWAI <br /> 2*y�< l OM,'PR <br /> ACCEPTED 011rY <br /> BY: t ,5� � EMPLOYEE#: DATE: 9 <br /> ASSIGNED TO: - .) r CA( I EMPLOYEE#: DATE: (' <br /> Date Service Completed (N already completed): I SERVICE CODE: J �J I P1 E: �- ()q <br /> Fee Amount: Amount Paid - '�,-(� Payment Date U <br /> Payment Type L- Invoice# Check# 2-1 b' I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />