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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '-,Z ccIr1 S0` <br /> OWNER/OPERATOR <br /> Lenzi Lanz Development LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 3222 E. Collier Road Acampo 95220 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 847 Cluff Ave., Suite B-1 <br /> Street Number Street Name <br /> CITY Lodi STATE CA ZIP 95240 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (209 ) 643-3215 005-146-07 PA 1700156 <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> Clc7 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Mike Toy CHECK If BILLING ADDRESS <br /> BUSINESS NAME Dillon&Murphy PHONE# ExT. <br /> 209 334-6613 <br /> HOME or MAILING ADDRESS P.O. BOX 2180 FAX# <br /> (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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �� DATE: 8/27/18 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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 asment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time i%"'J me or <br /> ufty <br /> my representative. W <br /> TYPE OF SERVICE REQUESTED: S�` S 1 hl I/l S��CAii^ <br /> COMMENTS: 8 '10 <br /> ' N � Y Af Cov�g <br /> THOF� �TY <br /> getAlYIJ D i <br /> ACCEPTED BY: P40 a J EMPLOYEE DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: , 2 .` <br /> Date Service Completed (if already completed): SERVICE CODE: c,—'Z--z PIE', <br /> Fee Amount: 3�-1 Amount Pa' 3dy, Payment Date <br /> Payment Type el,- Invoice# Check# �Dl Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />