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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ck-�)go <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS to <br /> Andrew La omarsino <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 16042 E Baker Road Linden 95236 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 642-6422 091-100-08 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CO E <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK If BILLING ADDRESS14 <br /> BUSINESS NAME PHONE# Exr. <br /> Dillon&Murphy 209 334-6613 <br /> HOME Or MAILING ADDRESS FAX# <br /> PO Box 2180 ( 209 ) 334-0723 <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 <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. <br /> APPLICANT'S SIGNATURE: % f DATE: <br /> PROPERTY/BUSINESs OWNER❑ E TOR/MANAGER OTHER AUTHORIZED AGENT Ig Civil Enginee <br /> IfAPPt[CANT is no the ILLING PARTY proof of authorization to sign is required Tire <br /> AUTHORIZATION TO RELE 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: <br /> RECEIVE <br /> 2 201 <br /> SAN JOAQUIN COU 4TY <br /> ACCEPTED BY: EMPLOYEE#: DATE: D ENT <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Co feted (if already ompleted): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid a Payment Date <br /> Payment Type Invoice# Check# f Received By: <br /> EHD 48-02-025 ` SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />