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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property Y FACILITY ID <br /> # SERVICE REQUEST# <br /> QCO-0�O52 <br /> OWNER/OPERATOR <br /> Frank Stonebarger CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 8408 N. Beecher Road Stockton 95215 <br /> Street Number I Direction Street Name C ity Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 401-6790 089-150-20 PA-1800066 <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Mike Toy <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME Dillon &Murphy PHONE# ExT. <br /> 209 334-6613 <br /> HOME or MAILING ADDRESS FAx# <br /> P.O. Box 2180 (209) 334-0723 <br /> CITY Lodi STATE Ca ZIP 95241 <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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 DERAL laws.--/" <br /> APPLICANT'S SIGNATURE: DATE: 10-2-18 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR NAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available anc ��r�lfl 11Nf it is provided to me or <br /> my representative. �c1ryV <br /> TYPE OF SERVICE REQUESTED: Soil Suitability Study <br /> COMMENTS: 05 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: E PLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Com leted (if already completed): SERVICE CODE: S PIE <br /> Fee Amount: - Amount Paid ,a) Payment Date s <br /> Payment Type ,C� Invoice# Check# l"�� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />