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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 <br /> Dwayne White CHECK if BILLING ADDRESS <br /> FACILITY NAME White Property <br /> SITE ADDRS <br /> 3390 & 31396 S. State Route 33 Tracy 95304 <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 31396 S. State Route 33 <br /> Street Number Street Name <br /> CITY Tracy STATE CA Z'P 95304 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (661 ) 706-3677 255-310-22 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( > 9( S <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, TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: I DATE: �a 2"n' <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, 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 same time it is <br /> provided to me or my representative. Aw <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability I Nitrate Loading Study PA <br /> COMMENTS: CE�VEp <br /> OCT o 2 2020 <br /> SAN JOAQUIN <br /> ALTH D 'FCpUNTA� <br /> HE <br /> ACCEPTED BY: ��� L EMPLOYEE#: DATE: �O17 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: < P 1 E: d 6 J0 <br /> Fee Amount: " �'�; Amount Paid (�O t Payment Date /O <br /> Payment Type �1 ;� Invoice# Check# �� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />