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1W 10028 U <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0-0 <br /> 6 7-49PI <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Chris and Diane Knoll <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 9296 E. ST RT j2/ Victor Road Lodi 95240 , <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( 209) 334-0750 051-120-56 <br /> PHONE#2 Exr. BOS DISTRICTLOCATION CODE <br /> c.. <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK if BILLING ADDRESSO <br /> BUSINESS NAME PHONE# En. <br /> Dillon & Murphy 209 334-6613 317 <br /> HOME or MAILING ADDRESS FAX# <br /> 847 N. Cluff Avenue, Suite A2 (209 ) 334-0723 <br /> CITY: Lodi STATE CA ZIP 95240 <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 prqject <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: <br /> PROkRTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT EJ Civil Engineer <br /> If APPLICANT is not t 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: tC (,Nc%� Suss„ '�cCv+���}�►•Inol F6ur, R� %� iv <br /> COMMENTS: <br /> DEC <br /> 922021 <br /> ` <br /> SANjyoRQUIN COtJn' <br /> MFACTy EIyT,� <br /> ACCEPTED BY: EMPLOYEE#: DATE: /210 <br /> 7 �� <br /> ASSIGNED TO: ~f[^m Is G EMPLOYEE#: DATE: 1,.--?10.71 -7 <br /> Date Service Completed (if already completed): SERVICE CODE: S,R3 PIE' d 03 <br /> Fee Amount: 3c7'-I Amount Paid — Payment Date 1212-12-1 c <br /> Payment Type ►� Invoice# Check# 5z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />