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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Joe Murphy CHECK if BILLING ADDRESS '410q5tX) OWNER/ OPERATOR PHONE # ExT' Dillon & Murphy Rita Busalacchi, Anna L. Solari, Francerca DeMello 209 334-6613 317 CHECK If BILLING ADDRESS® FACILITY NAME FAx # Fee Amount:��irl 847 N. Cluff Avenue, Suite A2 SITE ADDRESS 7327, 7339,7451, 747 7007 7111 7313 W 334-0723 March Lane STATE CA ZIP 95240 Stockton 95219 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 6110 Granica Ct. Street Number Street Name CITY STATE ZIP Stockton CA 95215 PHONE#1 209-986-1804, 209-93*3800 APN # 071-140-01,02,07,08, LAND USE APPLICATION# ( 209 ) 915-8132 1 09, 10, 11 PHONE #2 EXT. BOS DISTRICTLOCATI N CODE ( 209) 915-8132 CONTRACTOR / SERVICE REQUESTOR REQUESTOR r, f6m ) f? 4. Por f } t? Y i ? Joe Murphy CHECK if BILLING ADDRESS BUSINESS NAME EMPLOYEE #: PHONE # ExT' Dillon & Murphy DATE: 209 334-6613 317 HOME or MAILING ADDRESS FAx # Fee Amount:��irl 847 N. Cluff Avenue, Suite A2 (209) 334-0723 CITY Lodi STATE CA ZIP 95240 BILLING ACKNOWLEDGEMENT: 1, 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. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 12/1/2021 PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT OO Staff If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 the same time it is provided to me or my representative. A TYPE OF SERVICE REQUESTED: ct ce ""d _e"' b�U y F --ice r, f6m ) f? 4. Por f } t? Y i ? COMMENTS: D - OZZ 'q,PTM,q� ACCEPTED BY: EMPLOYEE #: DATE: JOai J� ASSIGNED TO: 1 iti1 C EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: S613 P I E: Fee Amount:��irl Amount Paid Payment Date �2 j Payment Type Invoice # Check # 11f Received By: EHD 48-02-025 REVISED 11/17/2003 M SR FORM (Golden Rod) G