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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE <br />ROOV(40 <br />REQUEST # <br />Pi <br />al-- <br />OWNER / OPERATOR <br />Todd Anderson CHECK if BILLING ADDRESS X <br />FACILITY NAME Clements Storage <br />SITE ADDRESS 22370 <br />Street Number <br />N. <br />Direction <br />Bezley Rd. <br />Street Name <br />Clements <br />City <br />95227 <br />Zip Code <br />HOME Of MAILING ADDRESS (If Different from Site Address) 24301 <br />Street Number <br />N. Tully Rd. <br />Street Name <br />CITY STATE ZIP Acampo CA 95220 <br />PHONE #1 EXT. <br />( 209 ) 482-1419 <br />APN # <br />019-260-54 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT L 1 LOCATION CODE <br />q CI <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Abby Racco CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Live Oak GeoEnvironmental <br />PHONE # <br />(209 <br />EXT. <br />)369-0375 <br />HOME or MAILING ADDRESS <br />407 W. Oak St. <br />FAx # <br />( ) <br />crry 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 th rk to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE a <br />APPLICANT'S SIGNATURE: <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 />provided to me or my representative. <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availalitterN the same time it is <br />ENT. , <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability / Nitrate Loading Study <br />COMMENTS: Af;(7411/ <br />20E2D1 <br />‘AQuiN SAN <br /> J0 C UN irE:.NV/RONM 0 <br />ENTAL TV cALTH DEpARTA4ENT <br />ACCEPTED BY: Z__ .....„----- L i EMPLOYEE #: DATE: sly107) <br />ASSIGNED TO: F R EMPLOYEE #: DATE: Sy/J/2 1 <br />Date Service Completed (if already completed): SERVICE CODE: S,. 3 PIE: 040c) <br />Fee Amount: 4 0 F Amount Pai -6 Payment Date .SILI2_1 <br />Received By: Payment Type Invoice # Check # S771( <br />DATE: •-C/.—/ 2 <br />PROPERTY / BUSINESS OWNERK. OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003