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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ,Sr,U 0-71�8 I3 <br /> OWNER/OPERATOR <br /> Brett Lagorio CxEarMBIwNO ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS [ <br /> 18660 Street Number Direenon Tobacco Roadtreet Name L1 Ci en 95 dada <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EaT. APN# LAND USE APPLICATION# <br /> (209 ) 351-1220 105-140-18 >, . _ /� — '� ��y) <br /> PHONE#2 Em BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK If BILLING ADORES <br /> BUSINESS NAME PHONE# En. <br /> Dillon & Murphy 209 334-6613 317 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 2180, Lodi, CA 95241 (209 ) 334-0723 <br /> CITLvodi STATECA <br /> 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,Stand rds, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 13 ERATOR/MANAGER [3 OTNER AUTHORIZED AGENT,E.f, C. %✓I L <br /> IfAPPLICANT is not th ILLING PARTY Proof of authorization to 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 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 /> COMMENTS: 7- RECEIVED <br /> 41-1 <br /> FEB 2 1 2017 <br /> M. Ir.E660vo 1411LI <br /> SAN JOAQUIN COUNTY <br /> / ENVIRONMENTAL <br /> ACCEPTED BY: 6�0&t an W EMPLOYEE#: � o7 1 I-7 <br /> ASSIGNED TO: n�! / c/ t EMPLOYEE#: DATE: � I ' <br /> Date Service Completed (if already completed): SERVICE CODE: f( C2 PIE: g (JJ <br /> Fee Amount: ,, Z 1 ILII Amount Paid 2,7 Payment Date 2, -A ( 7 <br /> Payment Type Ck$]\ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />