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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property V/ I-609'oj FACILITY ID # CHECK If BILLING ADDRESS SERVICE REQUEST # l&J PHONE # EXT. Dillon & Murphy Engineering 19 S2 0�29P OWNER / OPERATOR FAX # P.O. Box 2180 CHECK If BILLING ADDRESS Woodbridoe Partners Inc. c/o Jeff Crothers EMPLOYEE #: FACILITY NAME ASSIGNED TO:LX 61 1 t EMPLOYEE #: SITE ADDRESS 18846 Date Service Completed (if already completed): St. Rt. 99 E. Frontage Rd. SERVICE CODE: Acampo 95220 Street Number Direction Street Name Payment Date city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 119 Check # 2 LjQ L+0 E. Weber Ave. Street Number Street Name CITY STATE ZIP Stockton CA 95202 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 209) 986-4150 017-090-51 PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR V/ I-609'oj Josh McBride CHECK If BILLING ADDRESS BUSINESS NAME l&J PHONE # EXT. Dillon & Murphy Engineering 19 209 334-6613 HOME or MAILING ADDRESS FAX # P.O. 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 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 a F R� Ia APPLICANT'S SIGNATURE:)/ � DATE: 03/04/2022 PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑v OTHER AUTHORIZED AGENT ® Engineer If APPLICANT is not the BILL/NG 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 tiLsame time it is provided to me or my representative. w TYPE OF SERVICE REQUESTED: V/ I-609'oj COMMENTS: l&J 19 m R ANT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO:LX 61 1 t EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: '� o Amount Paid �4 I Payment Date C 22 Payment Type Invoice # Check # 2 LjQ L+0 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003