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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> #, <br /> S y0 ✓ <br /> OWNER/OPERATOR <br /> Ida Handel CHECK If BILLING ADDRESSO <br /> FACILITY NAME <br /> SITE ADDRESS 95240 <br /> 16696 N. Locust Tree Road Lodi <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) 334-1675 051-120-42, 94 <br /> PHONE#2 EXT. BOS DISTRICT , I LOCATION CODE <br /> ( ) `1 C C^ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Tristan Hartung CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Dillon & Murphy 2 )334-6613 <br /> HOME or MAILING ADDRESS Fax# <br /> PO Box 2180 ( ) <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 /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER OTHER AUTHORIZED AGENT IZJ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: SUr fG Le Q m cl S u 6s u r Cti Le GoA hi vK I"41c <br /> )o r+ rS 'D + r2-v BJir( <br /> 1.9 <br /> COMMENTS: /+ <br /> ECE/VEQ <br /> SAN JUL 0 2 2020 <br /> V/ROAQIIIN CDN <br /> H NMEN T1' <br /> ACCEPTED BY: EMPLOYEE#: DATE: � T o <br /> ASSIGNED TO: -_-5-1,J EMPLOYEE DATE: Z4.7 <br /> ac7Da0 <br /> Date Service Completed (if already completed): SERVICE CODE: S-03 P 1 E: 0 6J3 <br /> Fee Amount: t,30L Amount Paid -- Payment Date <br /> i <br /> Payment Typemvcp Invoice# Check# D Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />