Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# FSERVICE REQUEST# <br /> `�(Z( 0���K I <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Dan Cardoza <br /> FACILITY NAME <br /> SITE ADDRESS 22330 E Milton Road Linden 95236 <br /> Street Number I Direction Street Name city 7jp Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number 5 Veet Name <br /> CITY STATE ZIP <br /> PHONE#I ExT. APN# LAND USE APPLICATION# <br /> (209 ) 606-8310 093 -0 yo-19 <br /> PHONE#2 Ear. BOIS DISTRICT LOCATION CODE <br /> 1 ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK IT BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Dillon & Murphy 209 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 2180 ( 209) 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 /> 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,Standards,STATE and FEDERAL lag s. <br /> APPLICANT'S SIGNATURE: "y/ DATE: March 9, 2018 <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGER ❑ TRERAUTHORIZEDAGENT 0 Civil Engineer <br /> 1f APPLICANT is not 1176ILLING 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: <br /> coNNENrs: RECEIVED <br /> MAR 0 9 2010 <br /> SAN JOAQUIN COUNTY <br /> �0 `J ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: H ATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already comp ): SERVICE CODE: PIE• <br /> Fee Amount: �) Amount Paid C Payment Date 3 <br /> Payment Type C Invoice# Check# 3 J 3- Received y:5�?� <br /> EHD 4M2-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />