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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACiLi T'r iD# SERVICE REEQQUUEST# <br /> OWNER/OPERATOR <br /> Sherman Chiu CHECK If BILLING ADDRESS 0 <br /> FACILITY NAME Chiu Property <br /> SITE ADDRESS 8744S. Roberts Rd. Stockton 95206 <br /> Street Number Direction Street Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3314 TCesar Chavez St. <br /> Street Number Street Name <br /> CITY San Francisco STATE CA zip 94110 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (415) 279-1290 162-100-03 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) •,< <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Abby <br /> y 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 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FERE%L11aws.APPLICANT'S SIGNATURE: DATE: [ ( — S Z O Z C) <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 <br /> COMMENTS: <br /> 2020 <br /> SAN JOAQUIN COU <br /> ENVIRONMENTA1Y <br /> HEgLTH DEL <br /> PARTMENT <br /> ACCEPTED BY: -� 1 EMPLOYEE#: DATE: ,l F7._o;L) <br /> ASSIGNED TO: J 5 EMPLOYEE#: DATE: !I 9v 'dp <br /> Date Service Completed (if already completed): SERVICE CODE: j P 1 E: a� <br /> Fee Amount: L L'� Amount Paid O Payment Date 2C <br /> Payment Type Lucj?:� Invoice# Check# •Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />