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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/OPERATOR <br /> L6 Lagorio Land Company, c/o Jeff Lagorio CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITEADDRESS 16524 Ketcham Lane <br /> 16255 E. Hwy 26 Linden 95236 <br /> Street Number I Direction I Strain Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 14625 E. Comstock Road <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Linden CA 95236 <br /> PHONE#1 Ex. APH# 091-100-29 LAND USE APPLICATION# <br /> (209 ) 483-8861 1 091-110-11 >W 93- //>S <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 4 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Cheryl Gregory CHECK If BILLING ADDRESS <br /> Che <br /> BUSINESS NAME PHONE# Ext. <br /> Dillon 8 Murphy 1 209 1 334-6613 10 <br /> HOME or MAILING ADDRESS FAx# <br /> PO Box 2180 (209 ) 334-0723 <br /> CITY Lodi STATE CA ZIP 95241 <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 /> 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 laws. <br /> APPLICANT'S SIGNATURE: /L/// zvza� DATE; April 6, 2017 <br /> PROPERTY/BUSINESS OWNER❑ OPERATO /MANAGER ❑ THERAUTHORIZED AGENT® Staff <br /> /f APPLICANT is not the BILLING PARTY proof Of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE 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 t0 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: k l LG. S�(, e C0�{-Ny�„q-i, PkwW NT <br /> COMMENTS: RECEIVED <br /> 9 11-r rza/ v APR 0 6 20117 <br /> M'7''E—�-ed170 SAN JOAQUIN COUNTY <br /> &OAfl�j ) ENVIRONMENTAL <br /> ENT <br /> ACCEPTED BY:�w.{0...11 EMPLOYEE#: DATE: If,' <br /> ASSIGNED TO: GO � EMPLOYEE DATE: �{_(,-II-T <br /> Date Service Completed (if already completed): SERVICE CODE: -� P I E: 2� <br /> Fee Amount: 17 IS;() Amount Paid a")'g W Payment Date L{. <br /> Payment Type {. Invoice# Check# <br /> X405 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />