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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SI�U7� � <br /> OWNER/OPERATOR <br /> Brett Lagorio \ CHECK IT BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS E <br /> 18660 Tobacco Road Linden R <br /> SVee[Number Direction Street Name C{ 95 AEotla <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number [reel Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# ?BOS <br /> E APPLICATION# <br /> (209 ) 351-1220 105-140-18 — ()� (] <br /> PHONE#2 En. TRICT �� OCATIONC <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK If BILLING ADDRE <br /> BUSINESS NAME PHONE# EST. <br /> Dillon& Murphy 209 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 2180, Lodi, CA 95241 ( 209 ) 334-0723 <br /> CITY STATE zip <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,Sta t1ards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: to-Z-0—/ <br /> PROPERTY/BUSINESS OWN FR❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT® Civil Engineer <br /> IJAPPLICANT is n t 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: fizMllu <br /> R(ECrtEIVED <br /> COMMENTS: IY� •/� /i"� <br /> /� _ OCT L 0 207 <br /> / SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: Mkln EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: b <br /> Fee Amount: d' Amount Paid C9_1 Payment Date /01-;20117 <br /> Payment Type Crc:o.., I Invoice# Chcck-#— Received By: <br /> EHD 48-02-025 SR FORM(G(en Rod) <br /> REVISED 11/17/2003 <br />