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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 />BUSINESS NAME <br />EMPLOYEE #: <br />PHONE # EXT. <br />OWNER / OPERATOR <br />El <br />Zac Ellis <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Ellis Property <br />FAX # <br />SITE ADDRESS 2227 <br />W. <br />Sargent Rd. <br />CITY Lodi <br />Lodi <br />95242 <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 4411S. <br />Ernest St. <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />Visalia <br />CA 93277 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 303) 303-0599 <br />025-160-46 <br />PHONE #2 EXT. <br />BOS DISTRICT —7LOCATION <br />CODE/ <br />( ) <br />C G <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />❑ <br />Abby Racco <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />EMPLOYEE #: <br />PHONE # EXT. <br />Live Oak Geo Environmental <br />EMPLOYEE #: <br />209 369-0375 <br />HOME or MAILING ADDRESS <br />SERVICE CODE: a <br />FAX # <br />407 W. Oak St. <br />Fee Amount: p <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 FEDE L laws. <br />IS 'o'APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER ❑i PERAT / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is t 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 th ame time it is <br />provided to me or my representative. FAY <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability Nitrate Loading Study <br />COMMENTS: <br />ACCEPTED BY:–r2� �� <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: X I A <br />EMPLOYEE #: <br />d -1 <br />DATE: L111 <br />Date Service Completed (if already completed): <br />SERVICE CODE: a <br />P i E: U� <br />Fee Amount: p <br />Amount Paid UntoPayment <br />Date <br />22 <br />Payment Type <br />Invoice # <br />Check # O <br />Received By:W/-1 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />