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' '�An J(DAQUYD\f COUNTY ENVIRONMENTAL VTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Frop84 FACILITY ID# SERVICE REQUEST# <br /> 77 <br /> OWNER I OPERATOR <br /> ' Octavio Medina CHECK KBILLING ADDRESS® <br /> FAciurY NAME <br /> ' SITEADDRESS - <br /> 824 8. Hinkley Avenue Stockton 95295 <br /> Shah umber Direction Slreat omaZip Cate <br /> HOME OF WAILING ADDRESS (If Differant&am Site Addressp <br /> 2522 Grand Canal Blvd.l#� <br /> ' Stnet Humber <br /> CITY <br /> Stockton STATE ZIP <br /> CA 95207 <br /> PHONE99 WT'• APN# LAND USE APPLICATION# <br /> ( 209)470-9028 957-253-93 <br /> PHONE#2 8M• SOS Dcy LOCATIONCODE <br /> i ) <br /> ' C;ONTRAC COR 1 SERVICE RIEQUESTOR <br /> REQNESTOR <br /> Joe Murphy CrtEeKifalLLuvaAoo <br /> t BUSINESS NAME PNONE# ocr• <br /> Dillon&Murphy 209 334.8893 397 <br /> HOME Or MAILNG ADDRESS FAX# <br /> 847 N. Cluff Avenue, Suite A2 (209 ) 334-0723 <br /> C1TY Lodi STATE CA 2tP 95240 <br /> ULLING U, the undersigned property or business owner, operator or authorized agent of same, <br /> ' acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARmm'T hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> F also certify that 1 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 /> A 1FL)ICA T'S SIGN'A1CU1RE- � DATES <br /> ?RoPER'r,r i Busoms OWNER® PERATOR I MANAGER® '0uzRAUTaOR=DAGmx*l & Engineer <br /> ' If APPLICsiiVT is riot a 1Z:MPR;R7Y prooJ'ofanthorizadion to sign is required Tiele <br /> AUTUIIGIRUiEATM N TO]RELEASE INFORMATION.TION.When applicable,L 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 m me or my representative. <br /> TYPE OFSERVIDE REQUESTED: ��_ �Q n� T <br /> ' COMMENTS: Y �. <br /> AUG 2 3 �G�G <br /> ' SAN JOAQUIN CoUjqTj <br /> ENVIRONI9ENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: <br /> EMPLOYEE 9: EDATa:A�roNaDTo UJOArA{ EMPLOYEE#:Date Service Completed (tfal r completed): Ssawl CODE: c,Z3Fee Amou4- Amount Pa 3o�- Payment DatePaymentType 9mvolce# Check# g7$—� <br /> EHD 4&02-025 <br /> REVISED 111172003 SR FORM(Golden Rod) <br /> t <br />