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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Andrew La omarsino CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 16042 E Baker Road Linden 95236 <br /> Street Number I 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 ) 642-6422 091-100-08 }7�-r(ox, <br /> PHONE#2 EXT. BOS DISTRICT q <br /> LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Dillon&Murphy 209 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 2180 ( 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 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❑ O <br /> PERATOR/MANAGER OTHER AUTHORIZED AGENT Civil Engineer <br /> If APPLICANT is no 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. / A- <br /> TYPE OF SERVICE REQUESTED: 5 J N L r e V 1 e 1- 'q <br /> oft —0M FX <br /> COMMENTS: IVO <br /> 2020A <br /> yetr/yFN 47N , <br /> 44 <br /> ACCEPTED BY: �� �� EMPLOYEE M DATE: <br /> ASSIGNED TO: ^/'4 EMPLOYEE M DATE: S dJol <br /> Date Service Completed (if already Completed): SERVICE CODE: Sr�3 P/E. <br /> Fee Amount: 414 O'? Amount Paid D Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />