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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Abby Racco ACCEPTED BY: �_T �� EMPLOYEE #: q-40 7 1 OWNER/ OPERATOR PHONE # Calvin Tate CHECK If BILLING ADDRESS FACILITY NAME Tate Property 209 SITE ADDRESS 11880 E. Ada Ave. I FAX # Stockton 95215 Street Number Direction Street Name CITY Lodi city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 2932 Canal Dr. Street Number Street Name CITY STATE ZIP Stockton CA 95204 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 650) 520-7332 103-280-33 PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CEtV CHECK If BILLING ADDRESS Abby Racco ACCEPTED BY: �_T �� EMPLOYEE #: BUSINESS NAME ASSIGNED TO: S PHONE # EXT. Live Oak Geo Environmental 209 369-0375 HOME Or MAILING ADDRESS Fee Amount: SQ FAX # o0 J 01 407 W. Oak St. 3/112-2 ( ) CITY Lodi STATE CA Z'P 95240 BILLING ACKNOWLEDGEMENT: I, 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: y DATE: —_I( PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ IfAPPL/CANT 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 environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anc] at the same time it is provided to me or my representative. PAY TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study CEtV COMMENTS: MAR 0 4 2012 SAN dOAQUIE RompN Cout r, ACCEPTED BY: �_T �� EMPLOYEE #: DATE: ASSIGNED TO: S EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: �3 PIE: a Fee Amount: SQ Amount Paid o0 J 01 Payment Date 3/112-2 Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003