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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# IC �RyEQUEST# <br /> Residential �Y 0, 1C: <br /> OWNER/OPERATOR JJJ <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 20449 E. Oakwood Road Stockton 95215 <br /> Street Number Direction Street Name city FZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Oakwood Road <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95215 <br /> PHONE#1 EXT. APN# 185-080-35(portion) PBOSDiSTRICT <br /> LICATION# PA-2000062(MS) <br /> PHONE#2 EXT. LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Tristan Hartung CHECKifBILLING ADDRESS❑ <br /> BUSINESS NAME Dillon&Murphy Consulting Civil Engineers PHONE# ExT. <br /> 209 334-6613 <br /> HOME or MAILING ADDRESS PO BOX 2180 FAx# <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: (2 -I LC, C, <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ "��� - <br /> /fAPPL/CANT is not the BILLING PART},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: S V lPA <br /> COMMENTS: r <br /> VEO <br /> DEC 15 202 <br /> I0 <br /> N V/R N/N COu'v <br /> ff �" P <br /> ACCEPTED BY: `J`J t EMPLOYEE#: I CYC- DATE: 1 LA(7, <br /> ASSIGNED TO: / <br /> f -/ —EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): ` V SERVICE CODE: 5 2— P I E:: L <br /> Fee Amount: Amount Paid D — Payment Date 2 l� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVI.3ED 11/17/2003 <br />