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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 />PHONE # ExT• <br />ACCEPTED BY: <br />209 946-9882 <br />SRm®�341�7 <br />OWNER / OPERATOR <br />20157 Little John Road <br />Tracy LaBarber <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME <br />Date Service Completed (if already completed): <br />SITE ADDRESS 20157 <br />I <br />Little John Road <br />P I E:2602 <br />Stockton <br />95215 <br />Street Number <br />Direction <br />Street Name <br />Invoice # <br />Citv <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Same as site address <br />Street Number <br />Street Name <br />CITY <br />STATE Zip RE <br />CE <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />( 209 ) 817-5157 <br />185-080-540-000 <br />SEP , <br />PHONE #2 EXT. <br />BOS DISTRICT <br />L8A"2r -FADE <br />( 209 ) 946-9882 <br />4 <br />ENVvAAQUIN C <br />CONTRACTOR / SERVICE REQUESTOR <br />NT <br />Ep <br />021 <br />UNTy <br />N �EPgRTr ENT <br />REQUESTOR <br />Tracy LaBarber CHECK If BILLING ADDRESS❑ <br />BUSINESS NAME <br />PHONE # ExT• <br />ACCEPTED BY: <br />209 946-9882 <br />HOME or MAILING ADDRESS <br />FAx # <br />20157 Little John Road <br />( ) <br />CITY Stockton STATE CA ZIP 95215 <br />BILLING ACKNOWLEDGEMENT: 1, 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 FED AL laws. <br />A ;FLrCA-fIT"ti SrsriATUFE:�PP, t__ A-Y1nDATE: September 7, 2021 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR / 4 NAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is n t the BILLING P. 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: Soil Suitability <br />and Nitrate Loading Stud <br />COMMENTS: <br />Soil Suitability and Nitrate Loading Study Review <br />Digitally submitted; see attachment from e-mail dated 9/9/2021 to Aaron Gooderham <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: 9/10/2021 <br />ASSIGNED TO: Aaron GOOderham <br />EMPLOYEE#: <br />DATE: 9/20/2021 <br />Date Service Completed (if already completed): <br />SERVICE CODE: 523 <br />P I E:2602 <br />Fee Amount: $608 <br />Amount Pa O , �O <br />Payment Date <br />q110 <br />Payment Type , <br />Invoice # <br />Check # d - O <br />Receive By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />