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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUE`STI-L '�7 zco-?C/(' # <br /> OWNER/OPERATOR <br /> Kaiser Ranch, LLC (attn' Tarlochan Nijjar) CHECK if BILLING ADDRESS <br /> FACILITY NAME Kaiser Ranch I:LC- <br /> SITE ADDRESS 207 E. Durham Ferry Rd. Tracy 95304 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) P.O. Box 55 <br /> Street Number Street Name <br /> CITY Orinda STATE CA ZIP 94563 <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> (209) 610-8751 255-270-07 PA-1800128 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR ��[ <br /> REQUESTOR CHECK if BILLING ADDRESS 0 <br /> Abby Racco , <br /> BUSINESS NAME PHONE# EXT! <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. ( 1 <br /> CITY Lodi 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: iG�L,-� / DATE: A/ zivz F, <br /> PROPERTY/BUSINESS OWNER J(1 OPERATOR/MANAGER ❑ , OTHER AUTHORIZED AGENT❑ <br /> IJAPPLicANTT 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 andthe same time it is <br /> provided to me or my representative. q <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability Study <br /> COMMENTS: '0 1 0 <br /> �v <br /> y ,y�rr c ?� <br /> OFpq,Q�T T•zzNjY <br /> MFNr <br /> ACCEPTED BY: J�C MPLOYEE#: DATE: <br /> ASSIGNED TO: 1 EMPLOYEE#: DATE: ' <br /> Date Service Completed (if already completed): SERVICE CODE: S'z 3 /E: o I <br /> EeeAount: 30 Amount P � 1O� Payment Date fjt Type V Invoice# Check# R ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />