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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S q <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Richard Bozzano <br /> FACILITY NAME <br /> SITE ADDRESS 7116 <br /> E Arata Road Stockton 95215 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3000 N. Arata Road <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Stockton CA 95215 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 931-2692 A.P.N. 101-130-57 4- f 00 0/0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joel Montano 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 (209 ) 334-0723 <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 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 /> 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 SIGNATURE: DATE: 1111-Z12-011 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Staff <br /> /f APPLICANT is not the 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. p <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> 000/0 (KS) NOV / . <br /> %-10 gQ�/N� <br /> Rp Cp <br /> �Th�FpgR�UN7Y <br /> NT <br /> ACCEPTED BY: EMPLOYEE M () DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: i E: L_ <br /> Fee Amount: Amount Paid �8.� Payment Date II <br /> Payment Type Invoice# Check# Received BJ: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />