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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />COMMENTS: <br />SERVICE REQUEST # <br />BUSINESS NAME <br />G 17 <br />PHONE # EXT. <br />'Woo �07� <br />OWNER / OPERATOR <br />209 334-6613 <br />Dhanda Development Group, Inc. c/o Benny Dhanda <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME <br />PO Box 2180 <br />SITE ADDRESS 3271 <br />E <br />CITY Lodi <br />STATE Zip <br />EMPLOYEE M <br />CA 95241 <br />Date Service Completed (if already Completed): <br />SERVICE CODE: ` P i E, <br />Liberty Road <br />O Payment Date 2 l <br />Aca�mpo�95220 <br />Street Number <br />Dlrectlon <br />Street Name <br />eceived By: <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />1821 <br />Mitchell Road <br />Street Number <br />Street Name <br />CITY <br />Ceres <br />STATE ZIP <br />CA 95307 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( ) <br />005-100-01 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />ATION CODE <br />q <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />Tristan Hartung <br />11771 <br />CHECK if BILLING <br />COMMENTS: <br />ADDRESS <br />BUSINESS NAME <br />G 17 <br />PHONE # EXT. <br />Dillon & Murphy, Go Joe Murphy <br />209 334-6613 <br />HOME Or MAILING ADDRESS <br />FAX # <br />PO Box 2180 <br />EMPLOYEE M <br />( ) <br />CITY Lodi <br />STATE Zip <br />EMPLOYEE M <br />CA 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 ENvIRONMENT'AI, HEALTtI 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. c <br />APPLICANT'S SIGNATURE: DA'L'E: O _ �"� — 2 -912 - <br />PROPERTY <br />-9.2 -PROPERTY / BUSINESS OWNF,R❑ OPERATOR/ AGER ❑ OTHER AUTHORIZED AGENT ® Party Chief <br />If APPLICANT is not the BILLING PAR77. 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 HEAL'r" 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: <br />e vlew ~�M <br />COMMENTS: <br />RIC <br />ui�IIq. <br />WCL <br />G 17 <br />sAN�o ?021 <br />hSAL NVIR pNMF DUN <br />H �EpARTTAL <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: r� a <br />ASSIGNED TO: _ �� <br />EMPLOYEE M <br />DATE: 4 /17 <br />P <br />Date Service Completed (if already Completed): <br />SERVICE CODE: ` P i E, <br />Fee Amount: 4 6 0 � Amount Paid <br />O Payment Date 2 l <br />Payment TypeokffJ�1'1 <br />Invoice # <br />Check # 3� <br />eceived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />