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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> hro <br /> OWNER/OPERATOR 1' q <br /> Steve Coldani CHECK if BILLINO.ADDRESSI^■ <br /> FACILITY NAME Coldani Winery & Olive Mill <br /> SITE ADDRESS 3950 N <br /> Thornton Rd. Lodi 95242 <br /> Street Number Ir t oStreet N e <br /> HOME or MAILING ADDRESS (if Different from Site Address) 7F cl code <br /> 1305 W. Kettleman Ln. <br /> Street Number eat me <br /> CITY Lodi STATE CA zip 95242 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (209) 334-0527 055-140-23 PA-1300159 <br /> PHONE#2 Ev, <br /> ( ) SOS DISTRICT LOCATION CODE <br /> REtiUESTOR CONTRACTOR!SERVICE REQUESTOR <br /> Abby Racco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE EXT. <br /> # <br /> Live Oak GeoEnvironmentai 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St. <br /> CITY Lodi STATE ( ) ZIP 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.HEAE,Tfi 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 C"oder,Standards, and FED- L laws. <br /> APPLICANT'S SIGNATURE: <br /> DAME;. <br /> PROPERTY/BUSINESS OWNER ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLIC:AN is not the All Lt,VG PARTY.proof of authorization to sign is required Tule <br /> AIJTHORIZATION 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 st_ts <br /> provided to me or my representative. <br /> IV <br /> TYPE OF SERVICE REQUESTED: Review itymitrate Loading Study <br /> COMMENTS: <br /> o 2019 <br /> SFIORO <br /> VIN IV COU TY <br /> N&46-11 <br /> STN CE ARTME <br /> T <br /> ACCEPTED BY: <br /> EMPLOYEE#: <br /> DATE: <br /> ASSIGNED TO: EMPLOYEE#: <br /> DATE: <br /> Date Service Completed (if already completed): SERYICE CooE: vP 1 E: <br /> Fee Amaunt: Amount A cl i <br /> 30 d. 6 Payment ate �� <br /> Payment Type invoice# Check# <br /> a /b Received By: <br /> EHD 48-02-025 <br /> REVISED 1111712003 \�\\k f � SR FORM(Golden Rod) <br />