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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> oDi� � > 1 <br /> OWNER I OPERATOR <br /> CHECKif BILLING ADORES <br /> Bonner MendezS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 9855 ec Clements Road Linden 95236 <br /> Street Number I Ditection Stmet Name city Zia Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 126 Street Number Street Name <br /> CITY STATE LP <br /> Linden CA 95236 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> ( 209 ) 1 065-150-13, 065-150-14 <br /> PHONE 92 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK R BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ettr' <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 /> 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: \ {� I DATE: <br /> y 3 <br /> PROPERTY/BUSINESS OWNER❑ tPE TOR/MANAGER ❑ THERAUTHORIZED AGENTDa Engineer <br /> ffAPPLICANT is not thIL ING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEAS <br /> All_ <br /> 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 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. �p <br /> TYPE OF SERVICE REQUESTED: Mly <br /> COMMENTS: E"0 <br /> JUL 0 3 2018 <br /> SAN JOAQUIN COUNTY <br /> r &) <br /> HEAD HIROOpARTTAL <br /> LS <br /> ACCEPTED BY: 7 o)e evi EMPLOYEE#: DATE:.(-) <br /> ATE: <br /> ASSIGNED TO: EMPLOYEE#: S DATE: '1 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: Z 1p C <br /> Fee Amount: 3l I , Amount P I 3(� (� Payment Date 3 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />