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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SRoo$ 15�- a <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Robert Mara liano Sr. <br /> FACILITY NAME <br /> SITE ADDRESS 1123 N Jack Tone Road Stockton 95215 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 141 Street Number Street Name <br /> CITY Linden STATE ZIP <br /> CA 85236 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 481-7564 103-200-08 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joel Montano CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> Dillon & Murphy 334-6613 <br /> HOME or MA LING ADDRESS FAX# <br /> Pb 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 /> 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: --4= DATE: 12/18/2019 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT}{t ST� Fr <br /> If 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. <br /> TYPE OF SERVICE REQUESTED: / <br /> COMMENTS: CFV <br /> Ott 8 ?�19 <br /> hT IRDNMUW-ICD1Nry <br /> N SEP ENTAL <br /> ACCEPTED BY: EMPLOYEE M DATE: NT <br /> ASSIGNED TO: EMPLOYEE#: DATE: Cd r <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 <br /> Fee Amount: Amount Pai �D Payment Date <br /> Payment Type Invoice# Check# l Rece4ved y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />