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SAN JOAQ1 COUNTY ENVIRONMENTAL HEALTIvEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# 31 Z z OWNER/OPERATOR James Peterson CHECK if BILLING ADDRESS Ldnd FACILITY NAME Peterson Winery SITE ADDRESS J1075 W. Turner Rd. Lodi 95242 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 EXT. APN# LAND USE APPLICATION# (209 ) 329-7730 Brad Peterson 015-050-15 PA-04-403 PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Abby Racco CHECK if BILLING ADDRESS BUSINESS NAME PHONE# EXT. Neil O. Anderson & Associates Inc. 209 367-3701 HOME Or MAILING ADDRESS FAX# 902 Industrial Way (209 )369-4228 CITY Lodi STATE CA ZIP 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,Sta rds,STATEFEDE laws. APPLICANT'S SIGNATURE .. �- DATE: -711r D� : PROPERTY/BUSINESS OWNER OPERATOR/]MANAGER ❑ OTHER AUTHORIZED AGENT❑ If APPLICANT is ni 1 e BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO REL E INFORMATION: When applicable, I,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: � j � COMMENTS: Please review the attached Soil Suitability/Nitrate Loading S udy. The report revielk�A)6MEN f of $465 will be attached by the Petersons. If you have any questions, please do notECEIVE hesitate to call. bbY 5 JUL 1 9 20 SAN OA U�IrN� TY APPROVED BY:. EMPLOYEE#: �� DATE: ENTA_RTM Z ENT ASSIGNED T0: EMPLOYEE#: V DATE: Date Service Completed (if already completed): SERVICE CODE: ';2— Z7P!E: 2 Fee Amount: ?)71?— Amount Paid 19 OD Payment Date -� q 16) Payment Type Invoice# Check# ,1_D.�7— Received By: EHD 48-01-025 (S Iq —�o o k— SERVICE REQUEST FORM REVISED 6-5-02