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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 :L <br /> OWNER/OPERATOR <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 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 )887-2631 065-080-02 <br /> PHONE#2 EXT. BOS DISTRICT LOCATI CODE <br /> ( ) 9 11 <br /> (. <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Dillon&Murphy C/O CHECK if BILLING ADDRESS <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: 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 1 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: 2 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ THER AUTHORIZED AGENT❑ <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: 1 LtGP ytGO �ylj$u/i cL� RP of i`f re,V le IJ <br /> �C <br /> COMMENTS: J/ <br /> SAN Jo N?5 ?420 <br /> FNV/R QU//V co <br /> yE4CTy PAR MSN rY <br /> ACCEPTED BY: � ��� EMPLOYEE M DATE: /64 <br /> $d0'�O <br /> ASSIGNED TO: EMPLOYEE M DATE: (Id SJ 0 a 0 <br /> Date Service Completed (if already completed): SERVICE CODE: S d.� PIE: <br /> a l3 <br /> Fee Amount: 3 Amount Paid - - Payment Date 520 <br /> Payment Type Invoice# Check# 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />