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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property �(�( FACILITY ID # Tristan Hartung SERVICE REQUEST # CHECK if BILLING ADDRESS BUSINESS NAME Dillon & Murphy PHONE# COWNEResidential SC - OWNER/ OPERATOR R/OPERATOR �GTyo� 209 Jack Kautz HOME or MAILING ADDRESS CHECK if BILLING ADDRESS[--] FACILITY NAME tijFNrUN P.O Box 2180 SITE ADDRESS 11250 N.Micke CITY Lodi Grove Rd. ZIP 95241 Lodi 95240 Street Number cti Direon P / E:0 -Y Street Name Amount Paidu0slo city ZIP Code HOME or MAILING ADDRESS (If Different from Site Address) 5252 # E. Bear Creek Rd. Received By: Street Number Street Name CITY Lodi STATE CA ZIP 95240 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 209 ) 483-5395 059-140-57 R ZpODZZ3 PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR �(�( ,, �/��I Tristan Hartung t Lc� u�uVtS CHECK if BILLING ADDRESS BUSINESS NAME Dillon & Murphy PHONE# EXT. �GTyo� 209 334-6613 HOME or MAILING ADDRESS FAX # tijFNrUN P.O Box 2180 EMPLOYEE #: (209)334-0723 CITY Lodi STATE CA ZIP 95241 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and ED L laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MA R ❑ OTHER AUTHORIZED AGENT ® Party Chief If APPLICANT is not the BILLING PAR oof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED:UI/ �(�( ,, �/��I COMMENTS: j L 4l ZI. - �tVt\.!^✓ j �i5 /1i�JL 5 — t Lc� u�uVtS C /VF N�OgQJJ/N �GTyo� tijFNrUN ACCEPTED BY: / N H Y� i EMPLOYEE #: DATE: v NT ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: G P / E:0 -Y Fee Amount: 66 Amount Paidu0slo Payment Date �J 3 [Payment TypeAkGA42-11Invoice # Check # 2 2'��"O Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003