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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Sergio Martinez CHECK if BILLINGADDRESSE] <br /> FACILITY NAME <br /> SITE ADDRESS 3928E. Miner Avenue Stockton 95202 <br /> Street Number Foirection Street Name City Zlo Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 24242 Street Number PartridgeStreet LaNa e <br /> CITY STATE ZIP 95220 <br /> Acampo CA <br /> PHONE#1 ExT. A # LAND USE APPLICATION# <br /> (209 ) 993-7010 13-350-10 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Dillon & Murphy 20 334-6613 117 <br /> HOME or MAILING ADDRESS FAx# <br /> PO Box 2180 ( ) <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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, Standarc , STATE and FEDERAL la <br /> APPLICANT'S SIGNATURE: \� DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT IS not e LLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE 1 RMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time it is provided t0 me Or <br /> my representative. pIPA <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: AMPwkz <br /> H EURO"At COU <br /> EaCTyo���H,y <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> C <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Com leted (if al ady completed): SERVICE CODE: PIE: <br /> Fee Amount: 6 Amount Pai 3d ,D—,L-) Payment Dat / <br /> Payment Type Invoice# Check# 115-4L 3 Recei d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />