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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Abby Racco <br />SpZooIsy 2]11— <br />OWNER/OPERATOR <br />OWNER/ OPERATOR <br />PHONE # <br />Eugene Marsili <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Marsili Property <br />209 <br />SITE ADDRESS 3212 & 3225 <br />E. <br />I <br />Woodson Rd. <br />I <br />FAX # <br />Acampo <br />95220 <br />Street Number <br />Direction <br />Street Name <br />CITY Lodi <br />Ci <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 />Campo <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 />BOS DISTRICT L) <br />LOCATION CODE <br />( ) <br />I <br />10 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />Abby Racco <br />BUSINESS NAME <br />PHONE # <br />EXT. <br />Live Oak Geo Environmental <br />209 <br />369-0375 <br />HOME or MAILING ADDRESS <br />FAX # <br />407 W. Oak St. <br />( ) <br />CITY Lodi <br />STATE CA <br />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 and FEDERAL laws. `) '--7 <br />APPLICANT'S SIGNATURE:/"w DATE: / � Z <br />PROPERTY/ BUSINESS OWNERS( PERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPL/CANT 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 atPA a time it is <br />provided to me or my representative. Qc�.] -_ eAfT <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />Review Surface & Subsurface Contamination Report <br />`I V Eo <br />20 <br />08Vj021 <br />H"kTVIRONMEN UNry <br />1 DFP,gRTM�NT <br />ACCEPTED BY:-;=— GSL/ EMPLOYEE #: q1;/ DATE: g137/3 <br />I- <br />ASSIGNED TO: IZ L EMPLOYEE #: DATE: <-rAR 7 a <br />Date Service Completed (if already completed): SERVICE CODE: 5J 3 P i E. a �� <br />Fee AmountJ- �K 3� Amount Paid d� Payment Date I <br />Payment Type r Invoice # Check # �� V - Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />