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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br /># <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />nnSERVICE /IREQUEST <br />OWNER / OPERATOR <br />Eugene Marsili <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Marsili Property <br />FAX # <br />SITE ADDRESS 3212 & 3225 <br />E. <br />Woodson Rd. <br />CITY Lodi <br />Acampo <br />95220 <br />Street Number <br />Direction <br />Street Name <br />Cit <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 377 <br />Rode Rd. <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />Acam o <br />CA 95220 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209) 403-7373 <br />005-145-31 & -49 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Abby Racco <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />Live Oak GeoEnvironmental <br />209 369-0375 <br />HOME or MAILING ADDRESS <br />FAX # <br />407 W. Oak St. <br />( ) <br />CITY Lodi <br />STATE CA Z'P 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 nd FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ ANAGER 1:1OTHER AUTHORIZED AGENT EZ e o11JS VL7H N T <br />IfAPPLICANT 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 />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. pA1ei._ <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study AA���: ,, <br />it <br />COMMENTS: � <br />aV <br />h �jOgQV/N? 2 <br />02 <br />, <br />E9�Tti DF t <br />ENT <br />ACCEPTED BY: /-z- Z, L EMPLOYEE#: DATE: <br />ASSIGNED TO: R EMPLOYEE M DATE: <br />Date Service Completed (if already completed): SERVICE CODE: S3 3 P 1 E. a ®a <br />Fee Amount: C Amount Paid lK� r Payment Date l I I I 2I <br />Payment Type r Invoice # Check # 2 Z Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />