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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # P / E: Fee Amount: b �' BUSINESS NAME Live Oak Geo Environmental PHONE # 209 EXT' 369-0375 HOME Or MAILING ADDRESS Payment Type l�lXf OWNER/ OPERATOR Jacklyn Shaw, -1; -c K L - y A/ 4/►D Sf{ 1 Tim` CHECK if BILLING ADDRESS El FACILITY NAME Shaw Property G-- ✓ C N � ►1J/J S'!t LJ /�io pe c SITE ADDRESS 15766 N. DeVries Rd. Lodi 95242 Street Number Direction Street Name Ci Zi 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 # ( 562) 233-7300 025-170-03 PA -2100291 PHONE #2 EXT. ( ) I BU5 DISTRICT I LOCATION CGDE CONTRACTOR / SERVICE REOUESTOR REQUESTOR CHECK If BILLING ADDRESS Abby Racco P / E: Fee Amount: b �' BUSINESS NAME Live Oak Geo Environmental PHONE # 209 EXT' 369-0375 HOME Or MAILING ADDRESS Payment Type l�lXf FAx# 407 W. Oak St. 8—[ 1 ( ) CITY Lodi STATE CA zIP 95240 BILLING ACKNOWLEDGEMENT: 1, 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 and FEDERAL laws. APPLICANT'S SIGNATURE: I t Nt. DATE: PROPERTY/ BUSINESS OWNER /OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ IfAPPLICANT 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 envirom:rental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and ate same time it is provided to me or my representative. _ AYi#w&A#'ft. TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study COMMENTS: JAN 3 ENV1R0A1 COUN MST M,DE Aee1V M NT ACCEPTED BY: �� \ C u % I EMPLOYEE #: I DATE: / 4L-7 ASSIGNED TO: EMPLOYEE#: DATE: I/ Date Service Completed (if already completed): SERVICE CODE: �/ P / E: Fee Amount: b �' Amount Paid Payment Date Payment Type l�lXf Invoice # Check # 8—[ 1 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003