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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />OWNER/ OPERATOR <br />Gerard Warmerdam <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Warmerdam Property <br />209 369-0375 <br />SITE ADDR114950 & 19701 <br />y <br />N• <br />Disch Rd. <br />I <br />407 W. Oak St. <br />Lockeford <br />95237 <br />Street Number <br />Direction <br />Street Name <br />city <br />Ziv Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />19950 <br />1 N. Disch Rd. <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />Lockeford <br />CA 95237 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(209 ) 334-4904 <br />1 019-150-22&019-160-051 <br />A _ I quGzzG <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Abby Racco <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT. <br />Live Oak GeoEnvironmental <br />209 369-0375 <br />HOME or MAILING ADDRESS <br />FAX# <br />407 W. Oak St. <br />( 209) 369-0377 <br />CITY Lodi <br />STATE CA 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 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 appli ion and that the rk to be per ed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar , TA an E AL 1 S. / <br />APPLICANT'S SIGNATURE:T'z DATE: [ / <br />PROPERTY /BUSINESS OWNED 91- 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 enviro assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available/ill%�site <br />eitis <br />provided to me or my representative. /� 1Iad_ <br />TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report 5 -n— <br />COMMENTS: SAND �7 <br />H47-11 NV/Ro UiN CoU/y <br />Di p a MINTY <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE M DATE: 4 ' / <br />Date Service Completed (if already completed): SERVICE CODE: PIE: O <br />Fee Amount: 7> Amount P i D� Payment Date <br />Payment Type n'� 1 Invoice # I Check # /& /n I Received By: �Z109-1 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />