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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />sa 001.7)93 1 <br />OWNER! OPERATOR <br />Toheed Asghar CHECK if BILLING ADDRESS X <br />FACILITY NAME Eclipse Capital Property <br />SITE ADDRESS 26090 <br />Street Number <br />N. <br />Direction <br />Thornton Rd. <br />Street Name <br />Thornton r <br />City <br />95686 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 415 <br />Street Number <br />Beatrice Ct., Ste. H <br />Street Name <br />CITY STATE ZIP Brentwood CA 94513 <br />PHONE #1 Exr. <br />( 626) 260-2849 <br />APN # <br />001-150-48 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT 9 LOCATION CODE <br />I qC1 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Abby Racco CHECK if BILLING ADDRESS <br />BUSINESS NAME Live Oak GeoEnvironmental <br />PHONE # <br />(209 )369-0375 <br />Err. <br />HOME or MAILING ADDRESS <br />407 W. Oak St. <br />FAX # <br />( 1 <br />CITY STATE Lodi 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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: - <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br /> 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 EN VIRONMENTAL HEAL TI I DEPARTMENT as soon as it is available arid at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability / Nitrate Loading Study <br />COMMENTS: Jiic '''Air <br />1141,10,4, 7 202/ <br />EAtfri •Q/Jhv <br />/-Zio, RON CO UN <br />ACCEPTED BY: .'"......" 1., L, EMPLOYEE #: DATE: '7 r <br />Aft <br />ASSIGNED TO: <br />ri A <br />EMPLOYEE #: DATE: 7 7/2 1 <br />Date Service Completed (if already completed): SERVICE CODE: s-a 3 PIE: 04 0,2 <br />Fee Amount: t 6, 07 Amount Paid (60e .---, <br />9 <br />Payment Date 21 <br />Payment Type (04 p riej Invoice # Check # 2Ri 6(), Received By:CP-1 <br />DATE: ( <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003