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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # if BILLING ADDRESS BUSINESS NAME PHONE # EXT. Live Oak GeoEnvironmental OWNER/ OPERATOR 369-0375 Tracy Clarke CHECK if BILLING ADDRESS FACILITY NAME Clarke Property SITE ADDRESS 23702 N. I Bruella Rd. I ) Acampo 95220 Street Number Direction Street Name Cit Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) P.O. Box 1539Street Street Number Name CITY Lockeford STATE CA ZIP 95237 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 209) 747-0089 007-340-01 PA -2100252 PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK ❑ Abby Racco if BILLING ADDRESS BUSINESS NAME PHONE # EXT. Live Oak GeoEnvironmental 209 369-0375 HOME or MAILING ADDRESS FAX# 407 W. Oak St. ( ) CITY Lodi STATE CA Z'P 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 the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE an EDERAL I S. APPLICANT'S SIGNATURE: DATE: 1 Z — & — -2- PROPERTY / BusINESS 2-PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT P1 COACULTAW-r 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 environmentaUsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and aAYM# time it is provided to me or my representative. pp r... - 7* TYPE OF SERVICE REQUESTED: COMMENTS: Review Soil Suitability/Nitrate Loading Study U 12021 S �JOAQ lf?oUtN COUN7Y HrN DE MENT ACCEPTED BY: V\-/ U V EMPLOYEE #: DATE: ASSIGNED TO:a V� C 1 C C-� EMPLOYEE #: v DATE: I Z < Date Service Completed (if already completed): S� ERVICE CODE: � P1 E: Fee Amount:` Amount Pai4b5�� Payment Date Z' Payment Type Invoice # Check # Receive By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003