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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -F <br /> OWNER/OPERATOR <br /> DOMENIC LOMBARDI CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 15045 E FStockton <br /> Mariposa Road T95215 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 16998 E. Gawne Road <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Stockton CA 95215 <br /> PHONE#1 Ex'r. APN# LAND USE APPLICATION# <br /> ( 209 ) 649-6147 183-110-02 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <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 /> 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: _ 1 DATE: <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: rf— <br /> COMMENTS: rn <br /> AN <br /> V T�� ��+-.GX cJ�"��f�y� �V�,se%s�*�.a�� ���o.% ��� � •. <br /> ACCEPTED BY: EMPLOYEE#: O �he 7 DATE: <br /> ASSIGNED TO: t cr EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: J? Amount Paid n Payment Date 2� <br /> Payment Type Invoice# Check# Gl Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />