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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 01D1-0(,o!A'9 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 10351 E Acampo Road Acam o 95220 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 18600 Street NumbeFr Tobacco RoadStreetName <br /> CITY STT ZIP <br /> Linden 95236 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (209 ) 351-1220 I 017-180-10, 017-260-17 - goo 1- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Dillon& Murphy 209 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 2180 ( ) <br /> CITY Lodi STATE CA ZIP 95241 <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 HEM.T i DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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 SIGNATUR DATE: ZZ--1 <br /> PIi01'ER"1'Y/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER All"r110R1I,F.D AcEN'rX Civil Engineer <br /> ff APPLICANT is not h 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 HEALTi-I 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: D <br /> 40,- �(/1�S S�MAY Z 2 ?019 <br /> (f�� EN OAQU//y <br /> REACT I RDNMF DUN7Y <br /> N DEpAR M C <br /> N <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service COmple ed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid ()g Payment Date 5-1.2-2-11/ 9 <br /> Payment Type Invoice# Check# Received By: 616 —1 <br /> EHD 48-02-025 C a q I q I SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />