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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />❑ <br />FACILITY ID # <br />CHECK if BILLING ADDRESS <br />SERVICE REQUEST # <br />EMPLOYEE <br />PHONE # EXT. <br />Live Oak GeoEnviron mental <br />EMPLOYEE #: <br />209 369-0375 <br />HOME or MAILING ADDRESS <br />SERVICE CODE: 3 <br />FAX # <br />407 W. Oak St. <br />Fee Amount: 1 <br />OWNER / OPERATOR <br />c'TY Lodi <br />STATE CA Z'P 95240 <br />Eileen Kuil <br />Invoice # <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Kuil Property <br />S5M,12844 23050 <br />S. <br />Frederick Ave. <br />Ripon <br />95366 <br />I <br />Street Number <br />Direction <br />Street Name <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 22844 <br />S. Frederick Ave. <br />Street Number <br />Street Name <br />CITY Ripon <br />STATE CA <br />Zip 95366 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209) 599-4960 <br />228-130-27, -28, & -29 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <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 GeoEnviron mental <br />EMPLOYEE #: <br />209 369-0375 <br />HOME or MAILING ADDRESS <br />SERVICE CODE: 3 <br />FAX # <br />407 W. Oak St. <br />Fee Amount: 1 <br />( ) <br />c'TY 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 d FEDERAL laws. <br />APPLICANT'S SIGNATURE: r DATE: -7 - 11 - Z2 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT R C onlS-Vt-r eywT <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 at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report <br />pAYMENT <br />COMMENTS: <br />RECEIVED <br />JUL 11 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />ACCEPTEDBY:Z� L— <br />EMPLOYEE <br />DATE: <br />ASSIGNED TO: A <br />EMPLOYEE #: <br />DATE: 7/l1 a� <br />Date Service Completed (if already completed): <br />SERVICE CODE: 3 <br />P 1 E: d p3 <br />Fee Amount: 1 <br />Amount Paid 3l a _ <br />Payment Date�( <br />�2— Z <br />Payment Type <br />Invoice # <br />Check # 7 82 <br />Received By: <br />EHD 48-02-025 * D — C"S ~ 1, v ,f SR FORM (Golden Rod) <br />REVISED 11/17/2003 77 <br />