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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br /> o®gtocl <br /> OW ER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Terminous RV & Boat Storage V �{ <br /> SITE ADDRESS 15010 N. Glasscock Rd. Lodi 95242 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6705 N. EI Dorado St. <br /> c/o Kevin Swanson Street Number Street Name <br /> CITY STATE ZIP <br /> Stockton CA 95207 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 662-4184 025-030-04 <br /> PHONE#2 EXT. BOS DISTRICT / I LOCATION CODE <br /> ( ) SI11I <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,Stand d ,STATE andFE RAL la <br /> APPLICANT'S SIGNATURE: DATE: -3 2G1 - Z 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED -rllw <br /> AGENT lecr <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is require 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. mymmq <br /> TYPE OF SERVICE REQUESTED: Review Soil Suitability / Nitrate Loading Study <br /> COMMENTS: <br /> MAIC 2 9 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> d l 7 d I <br /> ASSIGNED TO: s EMPLOYEE M DATE:J <br /> Date Service Completed (if already completed): SERVICE CODE: 5 3 P 1 E: d 4 o <br /> Fee Amount: ��Q Amount Paid b _ Payment Date 3 Z <br /> Payment Type Invoice# Check# S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />