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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 57011eq ICE REQUWinery <br /> OWNER/OPERATOR <br /> Stokes & Lombardi Farms, LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Thomas Allen Vineyards&Windery <br /> SITE ADDRESS Lodi 95242 <br /> 5573 Woodbridge Road <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (209 ) 810-0058 011-170-52 r <br /> PHONE#2 EXT. BOS DISTRICT LOCA ON COD <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Reginald Katzakian CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> The Katzakian Company 209 481-1369 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 1176 ( ) <br /> CITY LodSTATE CA ZIP 95241 <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,ST TE nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER PERA R/MANAGER 0 OTHER AUTHORIZED AGENT Contractor <br /> If APPL/CANT is not the B/L 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. oe <br /> TYPE OF SERVICE REQUESTED: T <br /> COMMENTS: RECEIVED <br /> MAY 2 3 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: ATE: <br /> ASSIGNED TO: 4A 4, k-klA EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: v P I E <br /> Fee Amount: Amount Paid Crr) Payment Date <br /> Payment Type Invoice# Check# `q(4' Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />