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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (5AkwVE�'70 <br /> OWNER/OPERATOR <br /> Dwight Busalacchi CHECK If BILLING ADDRESS X <br /> FACILITY NAME Busalacchi Winery <br /> SITE ADDRESS 15467 E. Kettleman Ln. Lodi 95242 <br /> Street Number Direction Street Name City i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 8075 Wayland Rd. <br /> Street Number Street Name <br /> CITY Loomis STATE CA ZIP 95650 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 415) 531-6450 053-080-20 PA-1600200 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Abby Racco CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak Geo Environmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAx# <br /> 407 W. Oak St. ( ) <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,STA nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 5 ' 3 - 11 <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER ❑ OTHER AUTHORIZED AGENTS C"JS VL1?r N,T <br /> ifAPPL/CANT 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 aPAiit is <br /> provided to me or my representative. RECEIVED <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study <br /> COMMENTS: MAY 0 <br /> / SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: EMPLOYEE##: ( DATE: J? <br /> ASSIGNED TO: EMPLOYEE#: 6 DATE: g <br /> Date Service Completed (if alread completed): SERVICE CODE: P E: v L <br /> Fee Amount: 60 Amount Paid D Payment Date <br /> Payment Type Invoice# Check# / Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />