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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />❑ <br />FACILITY ID # <br />CHECK if BILLING ADDRESS <br />SERVICE REQUEST # <br />PHONE # EXT. <br />209 369-0375 <br />HOME or MAILING ADDRESS <br />ov qp <br />OWNER /OPERATOR <br />David Sasaki <br />CHECK if BILLING ADDRESS M <br />FACILITY NAME Sasaki Property <br />STATE CA z'P 95240 <br />SITE ADDRESS 5800E. <br />DATE:3 /'/-0 2Z. <br />Acampo Rd. <br />Acampo <br />DATE: <br />95220 <br />Street Number <br />Direction <br />Street Name <br />P I E:0602 <br />[FeeAmount: �Q� <br />Amount Pa'OZ) <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />6 2Z <br />Payment Type <br />Invoice # <br />Check # S2XS <br />P.O. Box 596Street <br />Street Number <br />Name <br />CITY <br />STATE <br />ZIP <br />Acampo <br />CA <br />95220 <br />PHONE #1 00-3213 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209) 333-2065 <br />017-320-15 <br />PHONE #2 EXT. <br />BOS DISTRICT I <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />❑ <br />Abby Racco <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Live Oak GeoEnvironmental <br />PHONE # EXT. <br />209 369-0375 <br />HOME or MAILING ADDRESS <br />FAX # <br />407 W. Oak St. <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, ST TE and FEDE laws. <br />APPLICANT'S SIGNATURE: DATE: 3 R zv <br />PROPERTY / BUSINESS OWNER❑ OPE OR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILGING 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. <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study <br />RMEIV7. <br />COMMENTS: <br />%D <br />MAR' 0 <br />2022 <br />j��OQIIIN CpUN <br />H � N400, At <br />NT <br />ACCEPTED BY: V u'7 �� <br />EMPLOYEE #:cl � % <br />DATE:3 /'/-0 2Z. <br />ASSIGNED TO: Jew -7— <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: S Z3 <br />P I E:0602 <br />[FeeAmount: �Q� <br />Amount Pa'OZ) <br />��U <br />Payment Date <br />6 2Z <br />Payment Type <br />Invoice # <br />Check # S2XS <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />