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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 />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />SAN <br />e% z q <br />OWNER /OPERATOR <br />NVIRONMENTAIL <br />Gabby Nunez <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Nunez Property <br />FAX # <br />SITE ADDRESS <br />( ) <br />CITY Lodi <br />STATE CA z'P 95240 <br />12622 <br />E. <br />Harney Ln. <br />Lodi <br />95240 <br />Street Number <br />Direction <br />Street Name <br />Cit <br />Zin Code <br />HOME or MAILING ADDRESS (If Different from Site Address) same <br />PIE: <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209) 401-3078 <br />063-240-07 <br />PHONE #2 Exr. <br />BOS DISTRICT / <br />LOCATION CO <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />❑ <br />Abby Racco <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />SAN <br />PHONE # EXT. <br />Live Oak Geo Environmental <br />NVIRONMENTAIL <br />209 369-0375 <br />HOME or MAILING ADDRESS <br />HEALTH DEPARTMENT <br />FAX # <br />407 W. Oak St. <br />( ) <br />CITY Lodi <br />STATE CA z'P 95240 <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 />1 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 FEDERAL laws. ; , <br />APPLICANT'S SIGNATURE: ;1111/1114/ l L � _ DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ Oj ,IF 2Au-ITIORIZEDAGENT ❑ <br />ff 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 enim"W"T assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL'rH DEPARTMENT as soon as it is availa[kgdF1VM time it is <br />provided to me or my representative. rR(G�+G <br />TYPE OF SERVICE REQUESTED: <br />Review Soil Suitability/Nitrate Loading Study <br />MAR 11 20 27 <br />COMMENTS: <br />SAN <br />NVIRONMENTAIL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />L <br />EMPLOYEE #: II ''' J <br />DATE: -)r <br />l <br />ASSIGNED TO: J�4 <br />� <br />EMPLOYEE #: <br />DATE: -^� <br />S C <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: Gi <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />