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SERVICE REQUEST EH0061SR revised 09/04/98 <br /> Type of Business or Property FACILITY ID# SERVICE REQU�ST <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> Roman Catholic Bishop of Stockton <br /> FACILn NAME <br /> same <br /> -T- <br /> SITE ADDRESS 1300 N Highway 99 <br /> Street Number Direction Street Name Type Suite# <br /> Mailing Address (If Different from Site Address) <br /> 610 S. Mills Avenue, <br /> CRY STATE ZIP <br /> Lodi CA 95242 <br /> PHONE#1 EXT APN# 061-07-02 LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REOUESTOR <br /> FEQUESTOR Joe Murphy <br /> BILLING PARTY❑ <br /> BUSINESS NAME PHONE# EXT. <br /> Dillon & Murphy 01 09) 334-6613 <br /> MAILING ADDRESS FAX# <br /> P.O. Box 2180 (209) 334-0723 <br /> CRY Lodi STATE CA ZIP 95241-21800 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br /> and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to <br /> 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 COUNTY <br /> Ordinance Codes, Standards, STATE and FE ERAL laws. <br /> APPLICANT SIGNATURE: DATE: 10/14/98 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ® Civil Engineer - <br /> If APPLICANT is not the BILLING PARTY Proof of authorization to sign Is required T i t I e <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, the owner or operator of the property located at the above site address, <br /> hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br /> P JeuC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> Lt <br /> RVICE REQUESTED: <br /> Soils Suitability Study <br /> COMMENTS ❑ SPECWL CONDITION(S)OF APPROVAL❑ OTHER _T_T_ _ ❑ <br /> OCT 141998 <br /> SAN JOACaUIN--OuN 1-1 <br /> PUBLIC HEALTH SERVICES <br /> ENVINCI MENIAL <br /> ...... ..--.. ._ .._..... .............. — - .....- -- - ------._ —- - <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: <br /> APPROVED BY: r t EMPLOYEE#: O Y DATE: Iq <br /> ASSIGNED T0: EMPLOYEE#: 6 (o `t DATE: 1 if �� <br /> Date Service Completed (if already comp) ed): SERVICE CODE: o�S l P 1 E: <br /> iFee Amount: C Amount Paid O Payment Date <br /> Payment Type I Invoice# _ Check# Reit it'rr By, <br />