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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />Abby Racco <br />SERVICE REQ`U�E�ST(J# <br />BUSINESS NAME <br />R <br />0 20 <br />h I'lR NINCOV2? <br />TyoF �� <br />PHONE # EXT. <br />Live Oak GeoEnvironmental <br />EMPLOYEE #: <br />OWNER/ OPERATOR <br />HOME or MAILING ADDRESS <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Rivermaid Trading Co. <br />407 W. Oak St. <br />SITE ADDRESS 6550 <br />E. <br />State Route 12 <br />SERVICE CODE: <br />Lodi <br />P / E: a ba <br />95240 <br />Street Number <br />Direction <br />Street Name <br />Payment Date 20 ZZ <br />Payment Type <br />Ci <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />I Received By: <br />C/o Tony Coyne, Coyne Construction Street Number <br />P.O. Box 2701 <br />Street Name <br />CITY Lodi <br />STATE CA <br />zIP 95241 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209) 666-5484 <br />049-120-04 <br />PA -2100295 <br />PHONE #2 ExT. <br />( ) <br />BOS DISTRICTCATION <br />9C, <br />LO CODE <br />Cl <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />❑ <br />Abby Racco <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />R <br />0 20 <br />h I'lR NINCOV2? <br />TyoF �� <br />PHONE # EXT. <br />Live Oak GeoEnvironmental <br />EMPLOYEE #: <br />209 369-0375 <br />HOME or MAILING ADDRESS <br />ASSIGNED TO: <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: DATE: 9 12- <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT less G� P1 Ty 4 <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 the same time it is <br />provided to me or my representative. <br />'4�'M��._ <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study <br />e <br />COMMENTS: <br />R <br />0 20 <br />h I'lR NINCOV2? <br />TyoF �� <br />ACCEPTED BY: <br />L.- L <br />EMPLOYEE #: <br />DATE: y �} .% <br />ASSIGNED TO: <br />�—yE^ k & <br />EMPLOYEE #: <br />DATE: y 0/5 <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E: a ba <br />Fee Amount: <br />O g <br />Amount Paid <br />d -� <br />Payment Date 20 ZZ <br />Payment Type <br />Invoice # Check # t l <br />I Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />