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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # �,ERVICE `F] Qr�UE1ST # OWNER /OPERATOR Roddan Construction, Inc. CHECK if BILLING ADDRESS FACILITY NAME BUSINESS NAME Live Oak Geo Environmental SITE ADDRESS 7681 W. I Li n ne Rd. I HOME or MAILING ADDRESS Tracy 95304 Street Number Direction Street Name ( ) Ci Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 289TYhn Kamps Way Street Numbe Street Name CITY Ripon STATE CA ZIP 95366 PHONE #1 EXT. APN # LAND USE APPLICATION # (209) 610-8041 248-080-38 PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR if BILLING Abby Racco CHECK ADDRESS BUSINESS NAME Live Oak Geo Environmental PHONE # 209 EXT. 369-0375 HOME or MAILING ADDRESS FAX # 407 W. Oak St. ( ) 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, ST TE nd F DEE AL la, s APPLICANT'S SIGNATURE: �/ / L �!�Gt/ DATE: PROPERTY / BUSINESS OWNER OPERA/R/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 and at the same time it is provided to me or my r ntative. am—TYPE OF SERVICE REQUESmhfigw IWM 111 Soil Suitability / Nitrate Loading - COMMENTS: MAI? 0 7 2022 MAR 0 7 2022 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ENVIRONMENTAL HEALTH RMITISERVICES ACCEPTED BY: EMPLOYEE #: DATE: 3/;7 ?- ASSIGNED TO: C- D EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: j 2 3 P 1 E:7,( p Fee Amount: �f'�" Amount Paid (20810 1 i Payment Date -q- /� Payment Type PAA 0 n Invoice # Check # �tyn R Received By: �� EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003