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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> Brent Workman <br /> FACILITY NAME <br /> SITE ADDRESS 21379 N. Mann Road Acampo 95220 <br /> Street Number Direction Street Name ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ems' APN# LAND USE APPLICATION# <br /> 12091810-4521 017-280-09 PA-1700251 <br /> PHONE#2 EI . BOS DISTRICT LOCATION CODE <br /> 1 1 al I �I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Mike Toy CHECK if BILLING ADDRESS❑ <br /> PHONE# Ex. <br /> BUSINESS NAME Dillon & Murphy 209 334-6613 <br /> HOME or MAILING ADDRESS p O. Box 2180 Fax# <br /> ( ) 334-0723 <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 /> 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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> If APPLICANTis not the BILLING 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 available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Lp(` PAYMENI <br /> COMMENTS: J RECEIVED <br /> APR 0 6 20% <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: ENT <br /> krto EMPLOYEE#: ATE L _I Vj <br /> ASSIGNED TO: EMPLOYEE#:: DATE: L4-.�j'I� <br /> f.d�-, Tet-l- <br /> Date Service Completed (it already completed): SERVICE CODE: S�� P 1 E: '� <br /> Fee Amount: " �OI-` . Amount Paid d Payment Date t{ 6 / <br /> Payment Type 1/ Invoice# Check# / Q Received By: <br /> EHD 48-02-025 l� SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />