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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTI-I DEPARTMENT SERVICE REQUEST Type of Business or Property EMPLOYEE #: FACILITY ID # EMPLOYEE #: SERVICE R QUEST # OWNER / OPERATOR StonecliffDevelopment, Inc. CHECK If BILLING ADDRESS❑ FACILITY NAME SIrE ADDRESS 2685�Numbe�rDlrecflon Lower Sacramento Road Campo 95220 26(�� r Liberty Road Street Name Galt 95632 Cit 7 HOME or MAILING ADDRESS (If Different from Site Address) zl Code CITY Street Number Street Name STATE Zip PHONE #1 Exr• APN # 005-030-007 LAND USE APPLICATION # (510 ) 468-9219 005-020-02 PHONE #2 (408 Exr. BOS DISTRICT LOCATION CODE ) 279-1520 7142 U01Y RACTOR / SERVICE REQUESTOR REQUESTOR Joe Murphy CHECK if BILLING ADDRESS© BUSINESS NAME PHONE # Exr. Dillon &Murphy 209 334-6613 HOME or MAILING ADDRESS FAX # PO Box 2180 ( ) CITY Lodi STATE CA Zip 95241 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAi. HEAI:rEI DEPARTMVNT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standh s, STA I! and i'EDER , la s. APPLICANT'S SIGNAI'U��R%E: _ DATE:_3= -" 23 Z '7 PROPERTY / 13USINESS OWNERL,J� 01' RA'Z'OR / MANAGER ❑ OTIII'7R AUTIIOIuzED AGENT ❑ J C� If APPLICANT is not ILLING PARTY, proof of authorization to sign is required Till e 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 Ffl,"ALTU DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED:sv� 1�ItE, �� ')bSuIrfgce Con-1gr,. h4 �gok7 ILqqar`1" COMMENTS: ACCEPTED BY: _ ' Z / EMPLOYEE #: ASSIGNED TO: EMPLOYEE #: - �-..-F ccu to direauy completes): Fee Amount: * 3 D y Amount Payment Type KJ'11 Invoice # EHD 48-02-02.5 REVISED 11/17/2003 SERVICE CODE: S a 3 OD Payment Date Check # �4 MAR 23 20 8ANj�0.1;Q22 UiN CD DATE: $ �A( DATE: 3 a3/a2 PI E: a�o3 By: SR FORM (Golden Rod)