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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SRO08 ► 5Ra <br /> OWNER/OPERATOR <br /> Annette & Todd Roddan CHECK if BILLING ADDRESS 0 <br /> FACILITY NAME Bella Gardens Wine Cellar <br /> SITE ADDRESS 23563S. Manteca Rd. Manteca 95337 <br /> et <br /> StreNumber Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 23601 S. Manteca Rd. <br /> Street Number Street Name <br /> CITY Manteca STATE CA Zip 95337 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 610-8042 226-110-46 PA-1800238 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 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 JOAQUfN <br /> COUNTY Ordinance Codes,Standards, ST a la / 0 <br /> APPLICANT'S SIGNATURE. DATE: X, ` <br /> PROPERTY/BUSINESS OWNER❑ OPERAW/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 d at the same time it is <br /> provided to me or my representative. OXViE <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study EIVE® <br /> COMMENTS: JAN o 2 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C P I E: <br /> Fee Amount: Amount Paid U Payment Date Z <br /> 0 <br /> Payment Type Invoice# Received By: <br /> NY WrI <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />