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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I�6A 2- <br /> OWNER <br /> OWNER/OPERATOR <br /> Stonecliff Development CHECK if BILLING ADDRESS <br /> FACILITY NAME Gudel Family Farms Subdivision <br /> SITE ADDRESS N Lower Sacramento Road Acampo 95220 <br /> 26850 Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 55 Market Street, Suite 1210 <br /> Street Number Street Name <br /> CITY San Jose STATE CA ZIP 95113 <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> ( ) 005-030-007 PA 0400074 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Dillon&Murphy C/O CHECKifBILLING ADDRESS® <br /> BUSINESS NAME Dillon&Murphy PHONE# ExT. <br /> 209 334-6613 <br /> HOME or MAILING ADDRESS p O. BOX 218 FAx# <br /> (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: DATE; <br /> In IAR-Q- 7-0 7-0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ AGER ❑ OTHER AUTHORIZED AGENT El <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: SOI C I 0I � / / <br /> COMMENTS: RtI&EIVEL) <br /> MAR 16 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> 14 <br /> ACCEPTED BY: M DAD EMPLOYEE#: DATE: <br /> ASSIGNED TO: �/���fV EMPLOYEE#: DATE: <br /> Date Service Completed (if�already completed): SERVICE CODE: PIE: 2��Z <br /> Fee Amount: 4k Amount Paid 0 -� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />