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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST ' <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> sl?d u (p <br /> OWNER/OPERATOR <br /> Manjinder Jhamat CHECK if BILLING ADDRESS El <br /> FACILITY NAME Jhamat Property <br /> SITE ADDRESS 5310 E. Las Positas Cir. Stockton 95212 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) same <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 405-0852 086-630-07 <br /> PHONE#2 EXT. BOS DISTRICT / i LOCATION CODE <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. ( ) <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. p <br /> APPLICANT'S SIGNATURE: DATE: I `� �✓" �1g <br /> PROPERTY/BUSINESS OWNER 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, 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 Soil Suitability/Nitrate Loading Study �C <br /> COMMENTS: <br /> sqN✓ X01 �O <br /> ti�s�ryo N�NCo1d�9 <br /> � FN <br /> ACCEPTED BY: EMPLOYEE#: / �� DATE: / <br /> ASSIGNED TO: VV VV EMPLOYEE#: tc)/ DATE: <br /> J t �V <br /> Date Service Completed If (ready ompleted): SERVICE CODE: 3 P I E: Z <br /> Fee Amount: Amount P i &0'U,f) Payment Date Z <br /> Payment Type /_ Invoice# Check# 7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />