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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 />CHECK if BILLING ADDRESS <br />I <br />FEB 1 4 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />SP <br />'004&J01 15 <br />OWNER/ OPERATOR <br />CK Bros. Carrier Inc. (Satbir Singh Rai) <br />CHECK if BILLINGADDRESSEl <br />FACILITY NAME Tech Truck &Auto, Inc. <br />407 W. Oak St. <br />SITE ADDRESS 4082 <br />S. <br />St. Rt. 99 E. Frontage Rd. <br />STATE CA Z'P 95240 <br />Stockton <br />95215 <br />Street Number <br />Direction <br />Street Name <br />Amount Paid — <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 16869 <br />1 <br />Gold Nugget Trail <br />Street Number <br />Street Name <br />CITY Lathrop <br />STATE CA ZIP 95330 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(510 > 993-6825 <br />179-172-56 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT i <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />E] <br />Abby Racco <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Live Oak GeoEnvironmental <br />FEB 1 4 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />PHONE # EXT. <br />209 369-0375 <br />HOME or MAILING ADDRESS <br />EMPLOYEE #: <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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ?� <br />DATE: <br />PROPERTY / BUSINESS OWNERM OPERATOR/ MANA R ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT 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. PAYMENT <br />TYPE OF SERVICE REQUESTED: <br />Review Soil Suitability Nitrate Loading Study <br />RECEIVE® <br />COMMENTS: <br />FEB 1 4 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: — 7 l <br />�� <br />EMPLOYEE #: <br />DATE: L—Ikd <br />ASSIGNED TO: A J <br />EMPLOYEE #: <br />DATE: a <br />Date Service Completed (if already Completed): <br />SERVICE CODE: S 3 <br />PIE: O <br />Fee Amount: 11l,409 <br />Amount Paid — <br />Payment Date <br />2-v 2— <br />Payment <br />Payment Type <br />Invoice # <br />Check # <br />Received y: AW <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />