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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S0' cogs 100 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Woodbrid e Partners Inc. c/o Jeff Crothers <br /> FACILITY NAME <br /> —7 <br /> SITE ADDRESS 18846 St. Rt. 99 E. Frontage Rd. Acampo 95220 <br /> Street Number Direction I Street Name city Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 119 E. Weber Ave. <br /> Street Number Street Name <br /> CITY STATE zip <br /> Stockton CA 95202 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 986-4150 017-090-51 <br /> PHONE#2 Exr. SOS DISTRICT --] LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Josh McBride CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> Dillon & Murphy Engineering 209 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. 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,Standards,STATE and FF rF� la <br /> APPLICANT'S SIGNATURE: / DATE: 03/04/2022 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Engineer <br /> If APPLICANT is not the BILLING 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tlb&same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: V/'O'C/lj <br /> COMMENTS: IqPR 6P <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: - DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: 6D� <br /> Fee Amount: Amount Paid L[ Payment Date ! 2 <br /> Payment Type Invoice# Check# 22CQ L+(D Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />