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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />�� `�� <br />Joe Murphy <br />FACILITY ID # <br />SERVICE REQUEST # <br />002 <br />PHONE # EXT• <br />Dillon & Murphy <br />209 334-6613 <br />HOME or MAILING ADDRESS <br />OWNER/ OPERATOR <br />FAx # <br />PO Box 2180 <br />MFHT <br />( > <br />CITY Lodi <br />STATE CA ZIP 95241 <br />CHECK If BILLING ADDRESS ❑ <br />Darin and Kathy Yra <br />DATE: ( 2 <br />ASSIGNED TO: ; <br />EMPLOYEE #: <br />FACILITY NAME <br />Date Service Completed (if already completed): <br />SERVICE CODE: i <br />SITE ADDRESS X1880 <br />E. <br />Copperopolis Road, <br />Amount Pai <br />Linden <br />95236 <br />E <br />Eastern Heigh Rg�d <br />Check # 22 <br />Lindgn <br />Street Number <br />Direction <br />a <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />22001 <br />E. <br />Copperopolis �{ <br />Street Number <br />SirOe�.me <br />CITY <br />STATE ZIP <br />Linden <br />CA 95236 <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />l 209-887-2324 <br />093-030-30, 13 <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />�� `�� <br />Joe Murphy <br />CHECK if BILLING ADDRES�a <br />BUSINESS NAME <br />002 <br />PHONE # EXT• <br />Dillon & Murphy <br />209 334-6613 <br />HOME or MAILING ADDRESS <br />RT �A, <br />FAx # <br />PO Box 2180 <br />MFHT <br />( > <br />CITY Lodi <br />STATE CA ZIP 95241 <br />BILLING ACKNOWLEDGEMENT: 1, 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 FEDER laws. 7 <br />APPLICANT'S SIGNATURE: � �� DATE: <br />PROPERTY / BUSINESS OWNER❑ dPERATOR / MANAGER ❑ I OTHER AUTIiORIZED AGENT ® Staff <br />ffAPPLICANT is not t /LL/NG PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 I/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. <br />TYPE OF SERVICE REQUESTED: <br />�� `�� <br />/V <br />COMMENTS: <br />002 <br />RT �A, <br />MFHT <br />ACCEPTED BY: <br />EMPLOYEE #: �L <br />DATE: ( 2 <br />ASSIGNED TO: ; <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: i <br />P I E: O <br />Fee Amount: <br />Amount Pai <br />. QD <br />Payment Date_ <br />Payment Type <br />Invoice # 1 <br />Check # 22 <br />Receive By: <br />LWA <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />