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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Ec c e C 2 n frA Wi VIA t V1 R �, r ' <br />FACILITY ID # <br />James Selke <br />SERVICE REQUEST # <br />Residential <br />BUSINESS NAME <br />DATE; <br />PHONE # <br />5 ROO 5441 7 <br />OWNER/ OPERATOR <br />DATE:I old G <br />CHECK If BILLING ADDRESS <br />Ivan Rico F.v��tnC�o <br />I1 /� j j <br />GbIL�:n C IfStG �)L� <br />gLI <br />FACILITY NAME <br />Amount Paid <br />PO Box 2180, <br />N/A <br />( 209) <br />334-0723 <br />SITE ADDRESS 55 <br />N <br />Olive Avenue <br />Stockton <br />95215 <br />Street Number <br />Direction <br />Street Name <br />Citv <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />1 <br />Street Number <br />Street Name <br />CITY <br />J( <br />STATE CAZIP 9 - <br />J <br />PHONE #1 EXT. <br />PHONE <br />APN # <br />LAND USE APPLICATION # <br />(209 ) 915-1359 <br />1157-210-33 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />a <br />LOCATION CODE <br />9<, <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Ec c e C 2 n frA Wi VIA t V1 R �, r ' <br />COMMENTS: <br />James Selke <br />ACCEPTED BY:� <br />CHECKlfBILLING ADDRESSE] <br />BUSINESS NAME <br />DATE; <br />PHONE # <br />EXT. <br />Dillon & Murphy <br />DATE:I old G <br />209 <br />334-6613 <br />HOME or MAILING ADDRESS <br />P I E: d(_103 <br />FAX# <br />Amount Paid <br />PO Box 2180, <br />Payment Date 10%2.91 2( <br />( 209) <br />334-0723 <br />CITY Lodi <br />STATE CA <br />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 />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,STA a DERAL laws. <br />APPLICANT'S SIGNATURE: DATE: �D�aS�ao a -I <br />PROPERTY/ BUSINESS OWNER❑ --OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 2f <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 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 OF SERVICE REQUESTED: S u f fo,c e_ 0,Y0 Sob' 5D I <br />Ec c e C 2 n frA Wi VIA t V1 R �, r ' <br />COMMENTS: <br />OCT Z9? o <br />S yVAQ1/NCoO?� <br />&kr/y Ep FNT� T). <br />ACCEPTED BY:� <br />EMPLOYEE #: <br />DATE; <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE:I old G <br />Date Service Completed (if already completed): <br />SERVICE CODE: E -2.3 <br />P I E: d(_103 <br />Fee Amount: * 3 OtI <br />Amount Paid <br />Payment Date 10%2.91 2( <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 />