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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SE (D6 776Y) '7 <br /> OWNER/OPERATOR <br /> COrIOpaSSI Partners L.P. CHECK 11 BILLING ADORESSO <br /> FACILITY NAME <br /> Canal Ranch <br /> SITEADDRESS P4009 N. Blossom Road Thornton 95686 <br /> Street Number I Direction Street Name Cit ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 11292 Alpine Road <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Stockton CA 95212 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (209 1 948-4022 1 011-030-21 &23 PA 1600196 <br /> PHONE#2 En. EPOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Mike Toy CHECK if BILLING ADDRESS \ <br /> BUSINESS NAME PHONE# En. <br /> Dillon&Murphy I ?Qq 1 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O.Box 2180 ( 2nq 1 334-0723 <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUrN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: •/ <br /> PROPERTY/BUSINESS OWNER OPERATOR/M[ANAGIl OTHER AUTHORIZED AGENT® <br /> IfAPPLICANT 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 <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: <br /> COMMENTS: <br /> R <br /> Ill//� vJIRO1VC C U <br /> FpgRT Tq< <br /> ACCEPTED BY: . .t EMPLOYEE M DATE: 3 <br /> ASSIGNED TO: EMPLOYEE#: DATE: 2> . <br /> Date Service Completed (If already completed): SERvicE CODE: �� 3 P 1 E: 2 <br /> Fee Amount: --' ' ' Amount P 2-7 g,dD Payment Date ,3 <br /> Payment Type Invoice# Check# 3 GJ- Recal ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />