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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />Tristan Hartung <br />SERVICE REQUEST # <br />Residential <br />ACCEPTED BY: <br />PHONE# EXT. <br />209 334-6613 <br />SDo azog <br />OWNER /OPERATOR <br />E] <br />Servillano Hortizuela <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />CITY Lodi <br />SITE ADDRESS 5347 <br />E. <br />I <br />Hildreth Lane <br />P E: a �3 <br />Stockton <br />95212 <br />Street Number <br />Direction <br />Street Name <br />Invoice # <br />"It <br />ZI Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />3173 <br />English Oak Circle <br />Street Number <br />Street Name <br />CITY Stockton <br />STATE CA Zip 95212 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( > <br />085-230-07 <br />PHONE #2 EXT. <br />BOS DISTRICT t <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />U,�� ,� j2e v <br />Tristan Hartung <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME Dillon & Murphy <br />ACCEPTED BY: <br />PHONE# EXT. <br />209 334-6613 <br />HOME or MAILING ADDRESS <br />DATE: 1 y TM'�NT <br />FAX # <br />PO Box 2180 <br />EMPLOYEE #: <br />( ) <br />CITY Lodi <br />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 FEDERAL 1 ws. <br />APPLICANT'S SIGNATURE: DATE: 13SE-PZ9i✓I <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER OTHER AUTHORIZED AGENT ® �a.✓ l�l.a4 <br />If APPLICANT is not the BILLING 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 HEALTII 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 />U,�� ,� j2e v <br />COMMENTS: S� <br />td�b <br />Nr <br />RE6i;ve6 <br />SEP 1 y 2421 <br />N <br />HE,qNV'a COU <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: 1 y TM'�NT <br />ASSIGNED TO: AIA <br />EMPLOYEE #: <br />DATE: Cl <br />Date service Completed (if already Completed): <br />SERVICE CODE: s 3 <br />P E: a �3 <br />Fee Amount: 30 �( <br />Amount P 3d <br />Payment Date <br />1 z- <br />Payment Type <br />Invoice # <br />Check # f's <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />