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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 REQUEST # <br />BUSINESS NAME <br />PHONE # EXT. <br />Sk, oo cgs <br />OWNER/ OPERATOR <br />Sunshine Tijero <br />CHECK If BILLING ADDRESS El <br />FACILITY NAME Tijero Property <br />SITE ADDRESS 23380 <br />S. <br />Austin Rd. <br />I <br />( ) <br />Ripon <br />95366 <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />same <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 925) 989-1574 <br />228-130-03 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT --7LOCATION <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Abby Racco <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />Live Oak GeoEnvironmental <br />209 369-0375 <br />HOME or MAILING ADDRESS <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 app 'cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TE and FEDERAL laws. t <br />APPLICANT'S SIGNATURE: DATE: 1� <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER OTHER AUTHORIZED AGENT ❑ <br />IfAPPLIC <br />A T 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 at the same time it is <br />provided to me or my representative. PA %'..._ <br />TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study"E - "'z'VT <br />COMMENTS:At P� 9 <br />SAN JOA <br />15 2022 <br />N ENV/R pNM CONT y <br />EALTH DRPARTTAL <br />NT <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: „a-✓� _ EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P I E: 7 <br />Fee Amount: Amount Paid Co 2 i Payment Date <br />Payment Type �► Invoice # Check # 2 2� Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />