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SAN JOAQUIIv COUNTY ENVIRONMENTAL HEALTI_ EPARTMENT <br /> SERVICE REQUEST PA220002 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> Darin and Kathy Yra <br /> FACILITY NAME <br /> SITE ADDRESS X1 to E. Copperopolis Road, Linden 95236 <br /> Street Number Dire Eon Eastern Heigh Rodd e Lind.n Zip code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> 22001 Street Number E. Copperopolis Foadme <br /> CITY STATE ZIP 95236 <br /> Linden CA <br /> PHONE 91 Exr. APN# LAND USE APPLICATION# <br /> ( 209-887-2324 093-030-30, 13 <br /> PHONE#2 ExT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK If BILLING ADORES <br /> BUSINESS NAME PHONE# Exr. <br /> Dillon & Murphy 209) 334-6613 <br /> HoME or MAILING ADDRESS FAx# <br /> PO Box 2180 ( ) <br /> CITY.Lodi STATE CA ZIP 95241 <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 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,Stand ds,STATE and FEDE laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ /MANAGER ❑ OTHER AUTHORIZED AGENT® StaffIfAPPLICANT is not�8.PERATOR <br /> ILLING 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 environment 1/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at > e time it is <br /> provided to me or my representative. "TZ e Y"�f, <br /> TYPE OF SERVICE REQUESTED: �` y'i�V� 1A <br /> COMMENTS: f 10 <br /> ,ONI�Cp <br /> ACCEPTED BY: <br /> n C%�//� n vim/ EMPLOYEE#: �L/Vi DATE: <br /> ASSIGNED TO: '��/v 1 \r1G G1 /( n �� EMPLOYEE#: DATE: /� <br /> Date Service Completed (if already completed): SERVICE CooE: L��-� P!E;�/�O/ <br /> Fee Amount: ?> Amount Pal �� Payment Date 2� <br /> Payment Type 0— Invoice# Check# 22 22 9 Received By: <br /> EHD 4,8-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />