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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID #--1 SERVICE REQUEST # Residential CHECK if BILLING ADDRESS BUSINESS NAME Dillon & Murphy PHONE# OWNER / OPERATOR /y FNLCNQUIN LWB Development 334-6613 CHECK if BILLING ADDRESS FACILITY NAME FAX # NT N/A ( 209) SITE ADDRESS 2 3982 I Village Drive 9 ZIP 95241 Clements 95227 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 8102 SERVICE CODE: j �2 Kelley Dr., Ste C Fee Amount: Street Number Street Name CITY Invoice # STATE ZIP Stockton CA 95209 PHONE #1 ExT APN # LAND USE APPLICATION # (209) 476-0425 1 009-300-06 & 11 PHONE #2 ExT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Bradley Handle CHECK if BILLING ADDRESS BUSINESS NAME Dillon & Murphy PHONE# EXT. /y FNLCNQUIN 209 334-6613 HOME or MAILING ADDRESS FAX # NT PO Box 2180 Lodi, CA 95241 ( 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 FEDERAL laws. APPLICANT'S SIGNATURE: 3N4a DATE: PROPERTY/ BUSINESS OWNER 11 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® ��p I C�� ✓1C, y .z/r If APPLIC-INT is not the BILLING PARDY proof of authorization to sign is required Ti de 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 thetle time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: MAI 2 820 /y FNLCNQUIN p�cot/ N� NT ACCEPTED BY:EMPLOYEE #: j DATE: ASSIGNED TO: j = > . EMPLOYEE #:� DATE: I Z 2 Date Service Completed If airea p ) p ( y Com leted : SERVICE CODE: j �2 � P I E: Fee Amount: Amount Paid D� D Payment Date Payment Type Invoice # Check # 272— Receiv d By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003