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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />COMMENTS: (L 1 I J'� L ( - (�iUc' Zw SSG yZ v+ < <br />SERVICE REQUEST # <br />Ve0 <br />DEC 0 2 ?021 <br />SAN M RONMF OUN7. <br />N UEP4Lr <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />EMPLOYEE #: <br />OWNER / OPERATOR <br />13 <br />Dillon & Murphy <br />CHECK If BILLING ADDRESS <br />Chris and Diane Knoll <br />334-6613 317 <br />FACILITY NAME <br />Date Service Completed (if already completed): <br />SITE ADDRESS <br />SERVICE CODE: <br />847 N. Cluff Avenue, Suite A2 <br />P I E: a 6 03 <br />(209 ) <br />334-0723 <br />9296E <br />STATE CA <br />ST RT );Z/ Victor Road <br />Lodi <br />95240 <br />Street Number <br />Diron <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EM <br />APN # <br />1 <br />LAND USE APPLICATION # \ <br />v <br />( 209) 334-0750 <br />051-120-56 <br />') I po 'L$ <br />PHONE #2 ExT. <br />( ) <br />BOS DISTRICT %� <br />1 11 <br />LOCATION CODE <br />9 of <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />RP r} R4 r <br />COMMENTS: (L 1 I J'� L ( - (�iUc' Zw SSG yZ v+ < <br />Joe Murphy <br />Ve0 <br />DEC 0 2 ?021 <br />SAN M RONMF OUN7. <br />N UEP4Lr <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />EMPLOYEE #: <br />PHONE# <br />EXT. <br />Dillon & Murphy <br />209 <br />334-6613 317 <br />HOME or MAILING ADDRESS <br />Date Service Completed (if already completed): <br />FAX# <br />SERVICE CODE: <br />847 N. Cluff Avenue, Suite A2 <br />P I E: a 6 03 <br />(209 ) <br />334-0723 <br />CITY Lodi <br />STATE CA <br />ZIP 95240 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <br />acknowledge that all site and/or project specific ENVIRONMENTAL. HEAL'rii DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />1 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: Zi <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER [3OTHER AUTHORIZED AGENT q CivilEngineer <br />If APPLICANT is not LBiLLiNG 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: Sc�f��?Cr ytCi1 SUbS��tt�IC�. Coy^}c�Y,1,1nGi�Suit <br />RP r} R4 r <br />COMMENTS: (L 1 I J'� L ( - (�iUc' Zw SSG yZ v+ < <br />/�L <br />Ve0 <br />DEC 0 2 ?021 <br />SAN M RONMF OUN7. <br />N UEP4Lr <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: 12107 j7 <br />ASSIGNED TO: YL. 1 Y <br />EMPLOYEE #: <br />DATE: 1,--210.71-17 <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />S,R3 <br />P I E: a 6 03 <br />Fee Amount: 0301-I <br />Amount Paid <br />o _ <br />Payment Date 12 <br />Payment Type <br />Invoice # <br />Check # 0!!5;2, <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />