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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Residential <br />FACILITY ID # SERVICE REQUEST <br />5 0)%9 <br /># <br />Oi 10 <br />OWNER / OPERATOR <br />Roy Hope CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS 22029 <br />Street Number <br />E. <br />Direction <br />Third Avenue <br />Street Name <br />Linden <br />City <br />95236 <br />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. <br />( ) 0930-480-02 <br />APN # oci34good, LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT L.,/ LOCATION CODE <br />q <br />CONTRACTOR / SERVICE RE UEST R <br />REQUESTOR <br />Tristan Hartung <br />_ <br />CHECK if BILLING ADDRESS X <br />BUSINESS NAME <br />Dillon & Murphy, do Joe Murphy <br />PHONE # <br />( 209 ) 334-6613 <br />EXT. <br />HOME or MAILING ADDRESS <br />PO Box 2180 <br />FAX # <br />( ) <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 HEALTI I 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- <br />PROPERTY / BUSINESS OWNEREI OPERATOR/MANAGI OTHER AUTHORIZED AGENT Party Chief <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 OE SERVICE REQUESTED: :1 .c.),,4-6c.it, :h Yy awl t)'--tie 1-0(-1 0 16"k, 5 tody Aev le w, <br />CMMENTS: <br />...-1 <br />Ok/J Yt els kiu,v bee', ,., corornuiii"cc,1-1ii vi t1-I1 Steo Jr7 sh 41 ..i)t tki pre4V/Ifeiv.r. <br />'Tete/vet') <br />AUG / 7 <br />SAN J f 2021 <br /> <br />.4Qui _ <br /> <br />P&143711441 111UILV 7 }' <br />ACCEPTED Z....-- 2--- EMPLOYEE #: BY:,----'7,1 <br />ASSIGNED TO: ir ,.5 EMPLOYEE #: AfEiv r DATE: gii/-74/ <br />Date Service Completed (if already completed): SERVICE CODE: P I E: <br />Fee Amount: .$ 6 0 ? --- Amount Paid <br />Q08 , Payment Date ci;3 <br />Received <br />t_t i2j <br />By: eam( Payment Type 0,0 p Invoice # Check # Hi.49) <br />Title <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod)