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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />E] <br />ERVICE REQUEST # <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Live Oak GeoEnvironmental <br />OWNER /OPERATOR <br />-9�M59 <br />El <br />Eileen Kuil <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Kuil Property <br />SF2Y%RE,2844, 23050 <br />S. <br />Frederick Ave. <br />) <br />Ripon <br />95366 <br />Street Number <br />Direction <br />Street Name <br />Clt <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 22844 <br />S. Frederick Ave. <br />I <br />Street Number <br />Street Name <br />CITY Ripon <br />STATE CA z'P 95366 <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />( 209) 599-4960 <br />228-130-27, -28, & -29 <br />PA -2200165 (MS) <br />PHONE #2 ExT• <br />( ) <br />BOS DISTRICTOCATION <br />IF <br />CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />E] <br />Abby Racco <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Live Oak GeoEnvironmental <br />PHONE# <br />209 <br />EXT. <br />369-0375 <br />HOME or MAILING ADDRESS <br />FAX # <br />407 W. Oak St. <br />( <br />) <br />CITY Lodi <br />STATE CA <br />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: "g DATE: i -;2' <br />PROPERTY / BUSINESS OWNERD OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 Soil Suitability / Nitrate Loading Study "T9 . P"' <br />COMMENTS: <br />SEP 30 Zo <br />E�QvfN <br />cov <br />ACCEPTED BY: L EMPLOYEE #: DATE: -7/3 .72 <br />ASSIGNED TO: AG EMPLOYEE #: DATE: 0 3Q aZ <br />Date Service Completed (if already completed): i SERVICECODE: 5 a P / E: <br />Fee Amount: a C+ I Amount P#V I Payment Date '7/36122 <br />I Payment Type (7P I Invoice # I Check # 211'6X? I Recei'ved By: 69 I <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />