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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> RVICE REQUEST# <br /> Type of Business or Property —E <br /> FACILITY ID# <br /> S(in� 0;-2,5 <br /> OWNER/OPERATOR <br /> Mario Carrasco, c/o Jack Kautz CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 11250 N. Micke Grove Rd. Lodi 95240 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 5252 E. Bear Creek Rd. <br /> Street Number Street Name <br /> CITY Lodi STATE CA zip 95240 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( ) 059-140-57 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Tristan Hartung CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME Dillon & Murphy PHONE# ExT. <br /> 209 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O 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 /> 1 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 an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR ANAGER ❑ OTHER AUTHORIZED AGENT® Staff <br /> If APPLICANT is not the BILL/NG PARTY,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 HEAuni DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. w <br /> ,17 <br /> TYPE OF SERVICE REQUESTED: SS 4 1A f W Ay a_ <br /> COMMENTS: N <br /> /�0 �- r►v��� � DEC 17 2020 OF <br /> ENVIRONMENTAL HEALT ►,/pgQ�1 , 2 Q <br /> PERMIT/SERVICES <br /> ACCEPTED BY: EMPLOYEE#: DATE: o T <br /> ASSIGNED TO: EMPLOYEE#: V DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P <br /> Fee Amount: Amount Paid / Payment Date <br /> Payment Type tnvoice# Check'# 3 l"�—� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />