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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Industrial (fulfillment Center) PHONE # EXT. 209 334-6613 HOME or MAILING ADDRESS PO BOX 2180 �J �2 IJIJQ L OWNER / OPERATOR CITY Lodi Amazon.com Services LLC CHECK if BILLING ADDRESS ❑ FACILITY NAME Date Service Completed (if already completed): Amazon.com Services LLC SERVICE CODE: ' SITE ADDRESS 12405 E. Brandt Road Amount Paid Lockeford 95237 Street Number Payment Type e L Street Name it Zi Code HOME or MAILING ADDRESS (If Different from Site Address) 410 Terry Avenue Street Number Street Name CITY Seattle STATE WA ZIP 98109 PHONE #1 ExT. APN # 051-320-060-000 LAND USE APPLICATION # ( 206 )266-1000 PHONE #2 EXT. BOS DISTRICT LOCATION CODE ( ) Gi l' CONTRACTOR / SERVICE REQUESTOR REQUESTOR Bradley Handel CHECK If BILLING ADDRESS BUSINESS NAME Dillon & Murphy Consulting Civil Engineers RECEIVED MAY 0 4 2022 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PHONE # EXT. 209 334-6613 HOME or MAILING ADDRESS PO BOX 2180 EMPLOYEE #: FAX # CITY Lodi STATE CA ZIP 95241 BILLING ACKNOWLEDGEMENT: I, 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. 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, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: �'j �a� CV a,/ I �,� C DATE: PROPERTY" / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AITTHORIZED AGENT If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 salve time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Jo I S )6,L,Iit�' CIyiC iv �r�<tF' Lgc.0%,vl S {t (f F-,,�iP„AYMENT COMMENTS: RECEIVED MAY 0 4 2022 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: . Z. EMPLOYEE #: DATE: ASSIGNED TO: C I` EMPLOYEE #: DATE: S �/ Date Service Completed (if already completed): SERVICE CODE: ' 1 P I E: d Fee Amount: 4 C> O'F Amount Paid (p �� Payment Date �7 Z 2-1 Payment Type e L Invoice # Check # 9265-3 Received By: Z�: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003