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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br /> Residential <br /> OWNER/OPERATOR <br /> Ida Handel CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS 16696 N. Locust Tree Road Lodi 95240 <br /> Street Number Direction Street Name City Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 16696 Locust Tree Road <br /> Street Number Street Name <br /> CITY Lodi STATE CA ZIP 95240 <br /> PHONE#1 EXT. APN# 051-120-42,94 LAND USE APPLICATION# PA-2000115(MS) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Tristan Hartung CHECK If BILLING 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 EDERAL laws. <br /> APPLICANT'S SIGNATURE: _ 1 <br /> / �I DATE: 2 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ ��w =�c <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. p <br /> TYPE OF SERVICE REQUESTED: <br /> 11 <br /> COMMENTS: <br /> SANJo15 <br /> C ?420 <br /> H RO%f DUI y7�, <br /> H oEpyR M H <br /> ACCEPTED BY: p EMPLOYEE#: DATE: <br /> ASSIGNED TO: tI(_11 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �� P/E: 2 Q <br /> Fee Amount: Amount Paid Ir Payment Date I �� <br /> Ei (_ <br /> Payment Type O Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />