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PA2100005 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALI rt DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # Al.3by Racco CHECK If BILLINGADDRESSE] SE/R�V'I10EE REQUEST # r PHONE# EXT. 209 369-0375 HOME or MAILING }ADDRESS UvIY "i0 OWNER I OPERATOR r if BILLING X MJDA Properties, LLC (Al Caton) STATE CA Z"'95240 CHECK ADDRESS FACILITY NAME MJDA Properties SITE ADDRESS 1'4503 I S. FCampbell Ave. Escalon 95320 Street Number Dir -lien Street Name Cltv ZID Code HOME or MALING ADDRESS (If Different from Site Address) 14907 S. Campbell Ave. Street Number Street Name CITY STATE ZIP Escalon CA 95320 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 209) 48CI-3457 207-320-12 & -21 PHONE #2 • EXT. t ) BOS DISTRICT L-� LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Al.3by Racco CHECK If BILLINGADDRESSE] BUSINESS NAME Live Oak GeoEnvironmental PHONE# EXT. 209 369-0375 HOME or MAILING }ADDRESS FAX # 407 W. Oak St. ( ) CITY Lodi STATE CA Z"'95240 BILLING ACKNO'IYLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all i ite and/or project specific ENVIRONMENTAL HEALTIJ DEPARTMENT hourly charges associated with this project or activity will be bille i to me or my business as identified on this form. I also certify that I have: 3repared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Cot s, Standards, ZEDa APPLICANT'S SIGNA URE: DATE: �! 2 Z'O PROPERTY/ BUSINESS OwNF..;i ❑ OPERATOR/ MANAGER F OTHER AUTHORIZED AGENT ❑ IfAPPL/C/,NT iS not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereb-y authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN�,COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my represo-i tative. &A TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report COMMENTS: yR6o ��D ��FpARNT ��Y ACCEPTED BY: EMPLOYEE #: J DATE: ldlq,llL C) r l ASSIGNED TO: J EMPLOYEE #: DATE: /d/�� ,a7�1 %(J Date Service Completed (If already .completed): SERVICE CODE: "-';22 PIE: o7�Q Fee Amount:: 30 L) Amount Pal 10, 0D Payment Date Payment Type Ok Invoice # I Check # / (� Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)