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APPLICANT'S SIGNATURE: PROPERTY! BUSINESS OWNER!: OPERATOR! MANAGER 0 DATE: I —I-T—Ana 1 OTHER AUTHORIZED AGENT 0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICEREQUEST # s poi-2, 178/ OWNER / OPERATOR Camillo Leventini CHECK if BILLING ADDRESS x FACILITY NAME Leventini / Leventini / Shoup /Alberti / Saco Property SITE ADDRESS 474-5-C)i 8458 & 8200 Street Number E. Direction Jahant Rd. & 23110 N. Dustin Rd. Street Name Acampo City 95220 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 3 z 3 cio )0stt 0-so" i 3/(1)04611"A-1 '`..-2-4-A 14C • Street Number to • c....L.Y$A ST" • Street Name CITY STATE ZIP LOr>1 CA CI S. 24 0 PHONE #1 EXT. ( 209) 484-6901 APN # 007-050-13, -47, portion of -46 LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT9 LOCATION COM- r/Ci CONTRACTOR / SERVICE REQUESTOR REQUESTOR Abby Racco CHECK if BILLING ADDRESS BUSINESS NAME Live Oak GeoEnvironmental PHONE # EXT. (209 )369-0375 HOME or MAILING ADDRESS 407 W. Oak St. FAX # ( ) Crrv Lodi STATE ZIP CA 95240 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thitre time it is TYPE OF SERVICE REQUESTED: Review Surface & Subsurface Contamination Report JVCe"47/tir nieb COMMENTS: -144, 2 n " 2021 lit,i476,04,1: coov 80E84,NT/14 7Y Tmeitt ACCEPTED BY: ,--- .c- z::._ EMPLOYEE #: DATE: /huh / ASSIGNED TO: _c . EMPLOYEE #: DATE: 1/4 04 / Date Service Completed (if already completed): SERVICE CODE: .i,:-,,) 3 P / E: jco: Fee Amount: 4'SoLi Amount Pai 304 00 Payment Date /2 y2 / Payment Type Ck Invoice # /2....2:7 Check # ecei d By: Al provided to me or my representative. A SR FORM (Golden Rod) EHD 48-02-025 REVISED 11/17/2003