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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '0o-1 q t <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> L6 Lagorgo Land Company clo Angelo Lagormo. Jr. <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 17508 Street Number D;Et;o„ Frazier Roac�treetName Lind 95236�e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 17706 E. Bentlesy etCt. <br /> N <br /> Street Number reef Name <br /> CITY STATE ZIP <br /> Linden CA 95236 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> t09 )483-7900 1065-100-08, 37, 38 PA-1700190 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK if BILLING ADDRESS <br /> BUSINESS NAME Dillon & Murphy PHONE# EXT. <br /> 209 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 2180 ( ) <br /> CITY Lodi STATE CA ZIP 95241 <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 /> I 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,StanV,07�rds, ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: October 16, 2018 <br /> PROPERTY/BUSINESS OWNER❑ RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANTisnLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 availabl the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: CIL C Ke <br /> COMMENTS: SAN / 6 "018 <br /> ENtOAQ(161/ l <br /> h�TH p 41gJV7Y <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 44 64 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Cofnpleted (if already completedf. SERVICE CODE: PIE: <br /> Fee Amount: Amount PauPe ate /O/W <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />