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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 <br /> OWNER/OPERATOR L 7 <br /> Eugene T.Stoddart,Successor Trustee of the Karen E.Stoddart Trust dated January 26,2007 CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 14953 E Tokay Colony Rd. Lodi 95240 <br /> Street Number Direction Street Name Cit ZI Cede <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 )887-2631 065-080-02 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Dillon&Murphy C/O CHECK If BILLING ADDRESSM <br /> BUSINESS NAME Dillon&Murphy PHONE# ExT. <br /> 209 334-6613 <br /> HOME or MAILING ADDRESS PO BOX 2180 FAX# <br /> (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 HEALTIi 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❑ OPERATOR/MANACr.R 10:1O'rIICR AU'I'tIORIT.�D AGCNT❑ <br /> If APPLICAN'1'is not the BILLING PARTY,proof of authorization to sign is required Tit t e <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 ENVIRONMI?N'I'AI,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: f 1.. Ir d?�/ e ,/ n►r <br /> COMMENTS: D <br /> SAN <br /> ?5 AQU 2020 <br /> N EN ORONM C�UIVTy <br /> STM pEp MEN <br /> ACCEPTED BY: �� 7 EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S-a3 PIE:: a 6 da <br /> Fee Amount: i 6 O E Amount Paid $a Payment Date z <br /> Payment Type ���Involce# ;Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />