Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> St2 0� 2 <br /> OWNER/OPERATOR <br /> CHECKIf BILLING ADDRES <br /> Brett Lagorio S <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 10351/21825 Acam�o Rd/Tretheway R Acampo 95220 <br /> Street Number Direction Street ame city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 18600 Tobacco Road Street N mbar Grand Canal Street N #e4 <br /> CITY STATE ZIP <br /> Linden CA 95236 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (209 ) 351-1220 1 017-180-10/017-260-17 <br /> PHONE92 Ex . BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Dillon & Murphy 209 1 334-6613 317 <br /> HOME or MAILING ADDRESS FAx# <br /> 847 N. Cluff Avenue, Suite A2 (209 ) 334-0723 <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> '5illed to me or my business as identified on this form. <br /> have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> 2 e Codes,Standards,STATE and FEDERAL laws. // <br /> SIGNATURE: DATE: N&40) v <br /> ESSOWNER❑ OItRATOR/MANAGER ❑ OTHER AUTHORIZED AGENT EZ Engineer <br /> 4PPLICANT is not l/I BI LING PARTY,proof of authorization t0 sign Is required Title <br /> :ON TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> cess, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> he SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> ,e or my representative. <br /> `` CQ rrlL ) iICE REQUESTED: �" 7„�CJtI 2 l•jp� yp.JA�tQ m/ l`� t <br /> RECEIVED <br /> JUN 2 5 2018 <br /> SAN JOAQUIN COUNTY_ <br /> ACCEPTED BY: EMPLOYEE#: M <br /> ASSIGNED TO: "mow-mo C6 EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: ��� PIE: j� <br /> Fee Amount: Amount Paid 3 Payment Date G <br /> Payment Type G Invoice# Check# I S6 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />