Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Daniel H. Cardoza, Jr. <br /> FACILITY NAME <br /> SITE ADDRESS 22330E Milton Road Linden 95236 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 22044 E. Milton Road <br /> Street Number Street Name <br /> Cm STATE Zip <br /> Linden, CA 95236 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 1209 ) 887-2037 1 lb 3 I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> I ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Joe Murphy <br /> BUSINESS NAME PHONE# En. <br /> Dillon & Murphy 209 334-6613 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: 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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 /> APPLICANT'S SIGNATURE: DATE: it-2119 <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 5 Engineer <br /> If APPLICANT is no the ILLING PARTY Proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEA INFORMATION: When applicable, I, 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. n +_ �[, J <br /> TYPE OF SERVICE REQUESTED: air:( L%( [ JI.�I'tL1 bI (I "'a' <br /> COMMENTS: RECEIVED <br /> AUG 3 1 2018 <br /> (� SAN JOAQUIN COUNTY <br /> O ENVIRON <br /> ACCEPTED BY: r' i' EMPLOYEEM <br /> ASSIGNEDTO: I Vl EMPLOYEE#: DATE: <br /> Date Service Completed I(if already completed): SERVICE CODE: PIE: ��0 <br /> Fee Amount: 31� 00 Amount Paid 30tp — Payment Date 19/31 Ind <br /> Payment Type invoice# Check# ;614 Received By: L6 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />