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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # CHECK if BILLING ADDRESS BUSINESS NAME Se 00 85 n-5 OWNER / OPERATOR CHECK If BILLING ADDRESS El FACILITY NAME II Vineto Mobile Home Park SITE ADDRESS 11662 N. I Ham Ln. Lodi 95240 Street Number Direction Street Name ity Zip Code HOME or MAILING ADDRESS (If Different from Site Address) c/o Environmental Enterprises, Inc. 71 Chicory Rd. Street Number Street Name CITY Chico STATE CA ZIP 95928 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 951) 212-9306 059-250-03 PHONE #Z EXT. ( 1 BOS DISTRICT LI LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR Abby Racco CHECK if BILLING ADDRESS BUSINESS NAME PHONE# EXT. Live Oak Geo Environmental 209 369-0375 HOME or MAILING ADDRESS FAX # 407 W. Oak St. ( 1 CITY Lodi STATE CA ZIP 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: ZAn10' DATE: `f - ! �/ - 7-2 PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® C CNSy L T n'-+ r If APPLICANT 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 environm j�Usite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available ant'litYze�ime it is provided to me or my representative. e&;Rh _ r TYPE OF SERVICE REQUESTED: COMMENTS: Review Soil Suitability/Nitrate Loading Study opV fU HM COVN2 ACCEPTED BY: —)2— Z Lr EMPLOYEE #: DATE: LI aQ a a ASSIGNED TO: �; l l K EMPLOYEE #: DATE: 1 Date Service Completed (if already completed): SERVICE CODE: s 3 P E. Fee Amount: � 0 F Amount Paid 0 b 9/ Payment Date 20 2.•) Payment Type Invoice # —Gmek? : I . 1',1 J q 14 p - l Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)