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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 I OPERATOR L -A <br /> Avo & Nonna Machado LP CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITEADDRESS 2288 N Murray Road Linden <br /> Street Number DIN ti 95236 <br /> Street Name CI ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 555 Street Number street Name <br /> CITY Linden STATE ZIP <br /> 95236 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 1 21 rpt - !q00069 <br /> PHONE#2 EXT. BOS DISTRICT LOCAT10 C E <br /> ( 1 ©b <br /> CONTRACTOR /SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK if BILLING ADDRESS 0 <br /> BUSINESS NAME PHONE# EXT. <br /> Dillon & Murphy 209 334-6613 317 <br /> HOME or MAILING ADDRESS FAX# <br /> 847 N. Cluff Ave. Sute A2 ( 209 ) 334-0723 <br /> CITY STATE CA ZIP <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. Q <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT D <br /> If APPLICANT is n t BILLING 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: VCL+IV <br /> CC <br /> AUG 2 p'NAN JOA <br /> ?019 <br /> NEgCAfv/ co <br /> R01V �N'y <br /> HO�p IAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Pai ��� Payment D v <br /> .� <br /> Payment Type Invoice# Check# Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />