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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PHONE# ExT• <br />209 334-6613 <br />REQUEST # <br />Industrial (fulfillment Center) <br />CITY Lodi STATE CA ZIP 95241 <br />EMPLOYEE #: <br />�ERVICE <br />S L <br />OWNER/ OPERATOR <br />Amazon.com Services LLC <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME <br />Amazon.com Services LLC <br />P / E: C) � Cha <br />SITE ADDRESS 12405 <br />E. <br />Brandt Road <br />Payment Date �" Z <br />Lockeford <br />-T <br />95237 <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zi Code <br />HOME or MAILING ADDRESS (if Different from Site Address) 410 <br />Terry Avenue <br />Street Number <br />Street Name <br />CITY Seattle <br />STATE WA ZIP 98109 <br />PHONE#1 ExT• <br />APN# 051-320-060-000 <br />LAND USE APPLICATION# <br />( 206 ) 266-1000 <br />PHONE#2 ExT• <br />BOS DISTRICT L� <br />LOCATION CODE <br />( ) <br />GG <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Bradley Handel CHECK if BILLING ADDRESS 6� <br />BUSINESS NAME Dillon & Murphy Consulting Civil Engineers <br />PHONE# ExT• <br />209 334-6613 <br />HOME or MAILING ADDRESS PO BOX 2180 <br />FAX# <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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT �J.1 <br />If APPLjc4,vT is not the BILLING PARTY, proof of authorization to sign is required <br />,-`/--2,D?2 <br />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 the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Sal S� ?ct�O, �t )L' �iv7� <br />N fry to LDr&,vlc S-Fvc', , [2 ,,jRAYMENT <br />COMMENTS: <br />RECEIVED <br />MAY 0 4 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: ----)2 <br />EMPLOYEE #: <br />DATE:�-2 <br />ASSIGNED TO:{. 11` <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: S a 3 <br />P / E: C) � Cha <br />Fee Amount: 0 <br />Amount Paid <br />ir?� <br />Payment Date �" Z <br />Payment Type C eL k <br />Invoice # <br />Check # 5 z 6 <br />Received By: <br />EHD 48-02-025 SR FO (Golden Rod) <br />REVISED 11/17/2003 <br />