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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if BILLING ADDRESS SER�VICE�E BUSINESS NAME OWNER /OPERATOR ExT. Ana & Luis Vidauri CHECK if BILLING ADDRESS FACILITY NAME Vidauri Property 369-0375 SITE ADDRESS 13180N. Jack Tone Rd. Lodi T95240 Street Number Direction Street Name STATE CA Cit Zip Code HOME or MAILING ADDRESS (If Different from Site Address) same Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # (702) 467-4930 065-020-33 PHONE #2 EXT. BOS DISTRICT LOCATION CODE ( ) 13 r r CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS Abby Racco BUSINESS NAME PHONE # ExT. Live Oak Geo Environmental 209 369-0375 HOME Or MAILING ADDRESS FAx # 407 W. Oak St. ( ) CITY Lodi STATE CA z"'95240 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, ST E and DE L 1 sA. APPLICANT'S SIGNATURE- DATE:OR�--)q 1 PROPERTY /BUSINESS OWNER❑ OPE TO / MANAG R OTHER AUTHORIZED AGENT ❑ If APPLICANT 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, hereby 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 representative. �A TYPE OF SERVICE REQUESTED: Review Soil Suitability Nitrate Loading Study ICC.' i* 4 COMMENTS: Sp S'�✓ 0 2021 EN Q(// H1V pFpA� O UIVI'Y FNT ACCEPTED BY: 1-�Z'— EMPLOYEE #: DATE: C'l3J d 7 ASSIGNED TO: F /' EMPLOYEE #: DATE: g13O� d I Date Service Completed (if already completed): SERVICE CODE: Sc? 3 //P I E: a b� Fee Amount: Amount Paid 7& 0S 00 Payment Date [ D Payment Type �!k Invoice # Check # ' 7Y.Z I Receiv d By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003