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SAN JOAQ,. COUNTY ENVIRONMENTAL HEALTH DEPARTMENT " <br /> 1%2200056 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sf-009 7 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> StonecliffDevelopment, Inc. <br /> FACILITY NAME <br /> SITE ADDRESS 26850 N Lower Sacramento Road Campo 95220 <br /> 26(�� E Liberty Road Galt 95632 <br /> reet Number Direction 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# 005-030-007 LAND USE APPLICATION# <br /> (510 ) 468-9219 005-020-02 <br /> PHONE#2 EXT. BOS DISTRICT LOCA N CODE <br /> (408 ) 279-1520 7142 C4 <br /> ' a <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Joe Murphy CHECK if BILLING ADDRESS© <br /> BUSINESS NAME PHONE# ExT. <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: 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,Standtr s,STATE and FE7P� <br /> APPLICANT'S SIGNATURE: DATE: 5, S3 - ZZ <br /> PROPCRTY/BUSINrsS5 OWNER OP'RATOR/MANAGCR 13OTHCIt AUTFIORIZCD AGCNT❑ <br /> IfAPPLICAN'P is not ILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INTORMATION: 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL FIEAurl-I DEPARTMENT'as soon as it is available and at the same time it is <br /> provided to me or my representative. g- <br /> TYPE OF SERVICE REQUESTED: <br /> �A` �GP,Vjt,ii' <br /> COMMENTS: <br /> MAR <br /> 23 <br /> 20 <br /> s� u1N Co2� <br /> rAL <br /> ACCEPTED BY: Z L_ EMPLOYEE#; DATE: _-/a <br /> rl <br /> ASSIGNEDTO: F, EMPLOYEE 9: DATE: 3/R3l52 <br /> Date Service Completed (if already completed): SERVICE CODE: S 3 PIE: LR I✓0-3 <br /> Fee Amount: 3 p= Amount Pa' 30 , DZ) Payment Date �2 <br /> Payment Type Invoice# Check# 2�(o Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />