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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# OERVICE REQUEST# <br /> SLO <br /> OWNER/OPERATOR <br /> Gabriel Ruvalcaba CHECK if BILLING ADDRESS El <br /> FACILITY NAME Ruvalcaba Property <br /> SITE ADDRESS 25795 1 S. Bird Rd. Tracy 95304 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 900 Dolores Ct. <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Tracy CA 95376 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 814-0158 252-140-09 <br /> PHONE i#2 EXT. BOS DISTRICT —7LOCATION CODE <br /> l ) S` / <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 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 and FEDErcZl <br /> !� ' `JAPPLICANT'S SIGNATURE: 'v DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anAat the same time it is <br /> provided to me or my representative. qY <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability / Nitrate Loading Study L'F/ <br /> COMMENTS: 44 <br /> '�? 04 20 <br /> N'71 oON COUP <br /> CTHOF���lY <br /> ACCEPTED BY: EMPLOYEE#: DATE: L/ J <br /> ASSIGNED TO: 5 EMPLOYEE#: DATE: a N <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: d�va <br /> Fee Amount: Amount Paid Payment Date OZ vv <br /> 0 <br /> Payment Type 0,219aInvoice# # 2p 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />