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Service Request Information <br /> Facility ID: Billing Account ID: IRecord ID:ISR0075440 DUpdate address <br /> Number: 3650 Direction:I E-E treet name: ACAMPO Facility Name: <br /> Unit type: IUnit: ity: JACAMPO Street type: RD-RD <br /> Site address: 3650 E ACAMPO RD ZIP Code: 95220 <br /> GIS Latitude: 38.1743432702 Longitude: -121.2715235674 Qr Place This Address on <br /> fl Add a Service Request Co Additional location information:3650 E ACAMPO RD <br /> Location: 99-UNINCORPORATED AREA PN: 01321052 ICopy Address With: <br /> Entered by: DSEDRA District code: 004-WINN,CHARLES Entered date: 18/10/2016 <br /> Update date: 8/10/2016 Update by: I DMARTORELLA <br /> --------- <br /> Property Owner Information <br /> Property owner: ANGELA ROGAN Property owner address: PO BOX 1521 Property owner city: LODI <br /> - - --- --- <br /> 'S ate: CA ZIP Code: 195242 Property owner phone 1: <br /> Phone 2: <br /> Requestor Information <br /> Requestor: Business name: D R JOLLEY CO. Requestor address: 2815 STRATFORD LN <br /> City: LODI tate: CA IP Code: 195242 <br /> Requestor Phone: (209)334-1395 <br /> Nature— <br /> of Service <br /> Nature of service: 4221-SEPTIC TANK DESTRUCTION P/E Code: 4221 <br /> P/E Description: 4221 -SEPTIC TANK DESTRUCTION n Special Permit <br /> Additional Information <br /> UST Retrofit <br /> [--]Leak Detector Sensor ■ Spill Bucket Drop Tube <br /> Cold Start _f Secondary Containment Other: <br /> Well Replacement <br /> Q Replaced well is Viable ]Replaced well is Non Viable <br /> _ All Well and Septic _ <br /> Fv-1Cosumnes Subbasin (5-22.16) [Eastern San Joaquin Subbasin(5-22.01) ElTracy Subbasin (5-22.15) <br /> -- Water Sampling -------- -- ------ <br /> OColiform and Gen Min(439 1) DBCP (4392) Arsenic(4393) <br /> ervice memo:ITO DEMO MODULAR HOME-ENFORCEMENT CASE. Received by: I FRANK GIRARDI <br /> Date: 8/10/2016 Assigned to: MICHAEL ESCOTTO Date: 8/10/2016 <br /> Plan type: (none) Amount paid: heck number: rchived: (none) <br /> Due date: ❑Requires further action <br /> Service Request Approval Dates <br /> Date request approved: Plan status: (none) (Date revision requested: <br /> Last activity date: 9/16/2016 Date revision submitted: Final inspection: <br /> if Add an a Add a Certified Profe <br />