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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR Michael David Winery (Kevin Phillips) CHECK if BILLING ADDRESS <br /> FACILITY NAME Phillips Farms <br /> SITE ADDRESS 14647 N. Ray Rd. Lodi 95242 <br /> Street Number i Direction Street Name City ZID Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 4580 W. Highway 12 <br /> Street Number Street Name <br /> CITY Lodi STATE CA zip 95242 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 368-7384 055-160-50, -29, -41, -51 PA-1300118 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. (209)369-0377 <br /> C'n Lodi STATE CA z'P 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 applicat'A apd that the wo o be performed will be done in accordance with all SAN JOAQUIN <br /> ,a <br /> COUNTY Ordinance Codes,Standards,ST ED7RAL s. <br /> APPLICANT'S SIGNATURE' DAT_ <br /> PROPERTY I BUSINESS OWNER OPERATORANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /f 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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Satre time it is <br /> provided to me or my representative. I`Ac� <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability/Nitrate Loading Study <br /> COMMENTS: 5 <br /> �I <br /> � qY <br /> � <br /> l?EP�R il�cc�r � 3 ynt,rl gNdoq 201 <br /> /11• ` c�co�?� j 30�� �tly IoM NTDU <br /> epgATM�N rY <br /> ACCEPTED BY: EMPLOYEE#: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E. <br /> Fee Amount: 6 OU Amount Pai (,sQ 0� Payment Date _�15A <br /> Payment Type Invoice# Check# ag 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />