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{y y <br /> PA 2 4 11SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> DOMENIC LOMBARDI CHECK if BILLINGADDRESSE] <br /> FACILITY NAME <br /> SITE ADDRESS 15045 EStockton <br /> Mariposa RoadF 95215 <br /> Street Number Direction Street Name citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 16998 <br /> E. Gawne Road <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Stockton CA 95215 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( 209 ) 649-6147 183-110-02 <br /> [PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joel Montano CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Dillon&Murphy 209 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 2180 (209- ) 334-0723 <br /> CITYLodiSTATE 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: /Z�/Zo Z Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Staff <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 the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> firAl919v <br /> ACCEPTED BY: EMPLOYEE#: j 7 DATE: <br /> ASSIGNED TO: W. EMPLOYEE#: DATE: <br /> E n L!" <br /> Date Service Completed (if already completed): SERVICE CODE: Z3 P I E:Z� j <br /> Fee Amount: $'30 Amount Paid �D Payment Date 22 <br /> Payment Type Invoice# Check# <br /> �a, Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />