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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Residential a 03�i-�jZ--�- <br /> OWNER/OPERATOR <br /> Sergio Martinez CHECK If BILLING ADDRESS❑ <br /> FAN/A CILITY NAME <br /> SITE ADDRESS N. Anteros Avenue Stockton 95215 <br /> 447 Street Number Direction Street Name CI ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 24242 Partridge Lane <br /> Street Number Street Name <br /> CITY STATE zip <br /> Acarno CA. 95220 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 )481-5872 / _ — '14760Z <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> REQUESCONTRACTOR/ SERVICE REQUESTOR <br /> Dillon&Murphy C/O Joe Murphy TOR CHECK if BILLING ADDRES <br /> Dillon <br /> BUSINESS NAME PHONE# EXT. <br /> Dillon&Murphy 209 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 2180 ( ) <br /> CITY Lodi STATE CA ZIP Lodi,CA.95241-2180 <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 HEALTFi 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 FERE L la s. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ O ERATOR/MANAGER ❑ OTHER AUTHORIZED AGEN� <br /> If .QQ� <br /> APPLICANT Is not t ILLING PARTY,proof of authorization to sign is require 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: <br /> (_. (`(i ►ticT� S t�'� iv V oma— rZ 9.�0"'� S <br /> "4A -/9a,2 ZZ3 % C <br /> Croy , <br /> ? ?0 <br /> A-AQU/N A7 <br /> ACCEPTED BY: EMPLOYEE M , } . <br /> ASSIGNED TO: (% �^ EMPLOYEE M lJ DATE: �( C <br /> Date Service Completed (if already completed): SERVICE CODE:�Z3 P 1 E: 0'�'C)�? <br /> Fee Amount: �2 Amount Paid i Payment Date <br /> Payment Type rM 0 6 Invoice# Check# /2o Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />