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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/OPERATOR <br /> FC Tracy Holdings, LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME FC Tracy Holdings, LLC <br /> SITE ADDRESS 3950 W. Lehman Rd. Tracy95304 <br /> Street Number Direction Street Name cit, <br /> it Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4598 S. Tracy Blvd., Ste. 160 <br /> Stral Street Name <br /> CITY Tracy STATE CA 7JP 95377 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 835-2224 255-040-20 PA-1800266 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <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. ( ) <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 /> 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,STAT FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 2/26/19 <br /> PROPERTY/BUSINESS OWNER 0 OPERLORN4ANAGER. 0 OTHER AUTHORIZED AGENT 0 <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 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sai ti it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study AdA <br /> COMMENTS: <br /> y �oq <br /> "-�`14TiyO <br /> gCTy,yOF?UN®N ERT171, <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: AiimfAq EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 7,,17 P 1 E:0&2' <br /> Fee Amount: Amount Paid (� Payment Date <br /> Payment Type �C_ Invoice# Check# lb� Rec ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />