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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK if BILLING ADDRESS <br />SERVICE REQUEST # <br />awt'4" rL t - � <br />PHONE# <br />209 <br />ExT. <br />334-6613 <br />HOME Or MAILING ADDRESS <br />P.O. Box 2180 <br />OWNER/ OPERATOR <br />FAX# <br />( 209 ) <br />Victor Lagorio <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />ZIP 95241 <br />SITEADDRESS 14351 <br />E <br />Comstock Road95236 <br />Linden <br />T <br />Street Number <br />Direction <br />Street Name <br />EMPLOYEE M <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />SERVICE CODE: �a 3 <br />P I E: 6� 3 <br />Street Number <br />�� <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 Ex r. <br />APN # <br />LAND USE APPLICATION # <br />( 209) 482-6324 <br />091-020-36 & 37 <br />Received By: <br />PHONE #2 EXT. <br />BOS DISTRICT 1 <br />—E17 <br />LOCATION CODE <br />( ) <br />I <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Mike Toy <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME Dillon & Murphy <br />awt'4" rL t - � <br />PHONE# <br />209 <br />ExT. <br />334-6613 <br />HOME Or MAILING ADDRESS <br />P.O. Box 2180 <br />Sgiy,/pA <br />fi ENVlRp�tNC <br />FAX# <br />( 209 ) <br />334-0723 <br />CITY Lodi <br />STATE CA <br />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, HEALTli 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: 09/07/21 <br />PROPERTY/ BUSINESS OWNER❑ PERATOR / MANAG R OTIIER AUTHORILF,D AGENT ❑ <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 ENVIRONMFNTAI. 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: SU Y Le C� l7 U SU �Su / r� G e n �ln {� t >7 ti 7 0 Ise n� e J C W • <br />Nr <br />D <br />COMMENTS: (,J� (A <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />121 <br />N7). <br />VT <br />awt'4" rL t - � <br />SEP 0 7 <br />Sgiy,/pA <br />fi ENVlRp�tNC <br />SACTy DEp Ely i <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: 7 R7 9 <br />ASSIGNED TO: <br />J <br />EMPLOYEE M <br />DATE: 9/7 , % <br />Date Service Completed (if already completed): <br />SERVICE CODE: �a 3 <br />P I E: 6� 3 <br />Fee Amount: <br />�� <br />Amount P <br />. O <br />Payment Date u <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />121 <br />N7). <br />VT <br />