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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -spo lm <br /> OWNER/OPERATOR <br /> Rudy & Toni Mussi, Lory & Victoria Mussi CHECK if BILLING ADDRESS <br /> FACILITY NAME Mussi Property <br /> SITE ADDRESS 6565 W. Howard Rd. Stockton 95206 <br /> Street Number I Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4362W. Muller Rd. <br /> Street Number Street Name <br /> c'n" Stockton STATE CA ZIP 95206 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 601-5933 189-220-03 <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 GeoEnviron mental 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: 1, 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: `� '" ! DATE: 3--l (o'ZL) <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT C O rsS JL-t N'f` <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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study NIE <br /> COMMENTS: Vt b <br /> MAR 16 ?020 <br /> MF LIJOA <br /> OIV& <br /> R1 ou/VTy <br /> H DEPARTM C <br /> ACCEPTED BY: EMPLOYEE#: V V�e DATE: 7>0-0 <br /> ASSIGNED TO: �P\_ EMPLOYEE#: Q S DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: l <br /> Fee Amount: 6 Amount Pai G Payment Date 3 1� z' <br /> Payment TypeClk— <br /> Invoice# Check# Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />