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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />3 10055f3 <br />OWNER! OPERATOR <br />Ajay Kumar CHECK if BILLING ADDRESS x <br />FACILITY NAME Kumar Property <br />SITE ADDRESS 16895 <br />Street Number <br />W. <br />Direction <br />Grant Line Rd. <br />Street Name <br />Tracy <br />City <br />95304 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 420 <br />Street Number <br />Acoma Way <br />Street Name <br />CITY STATE ZIP Fremont CA 94539 <br />PHONE #1 EXT. <br />( 510) 938-3070 <br />APN # <br />209-140-07 <br />LAND USE APPLICATION # ,----) <br />I <br />PHONE #2 <br />( ) <br />EXT. BOS DISTRICT „... LOCATION CODE <br />4 g <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Abby Racco CHECK if BILLING ADDRESS <br />BUSINESS NAME Oak GeoEnviron mental <br />EXT. <br />Live <br />PHONE # <br />(209 )369-0375 <br />HOME or MAILING ADDRESS 407 W. Oak St. <br />FAx # <br />( ) <br />CITY Lodi STATE c A 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, STATE anj FEDERAL la -. <br />APPLICANT'S SIGNATURE: DATE: 4-/ - 2-1- I 'I <br />PROPERTY! BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT <br /> <br />If APPLICANT is not the BILLING PAR7'Y, 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 thiosame time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study jnrkbk3rs <br />1 <br />iV"' <br />it0- COMMENTS: 4PR <br />2 8 414, a 2049 <br />6N;!,40.7 <br />A/0:4;14 '7 47 . <br />ACCEPTED BY: 6t11--J- EMPLOYEE #: DATE: j(vi /1 7 <br />ASSIGNED TO: 7 eV)—/W42 EMPLOYEE #: DATE: T <br />Date Service Completed (if already completed): SERVICE CODE: ,c P1 E:2,6) —2,/ <br />Fee Amount: e_ h76 g Amount Paid 4 I os • on Payment Date LI I 1 <br />Payment Type() 1 p ro d _., Invoice # Check # 540 Received By: ,V) <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003