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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST#S�� ooss--T21 <br /> OWNER/OPERATOR <br /> Rita Busalacchi, Anna L. Solari, Francerca DeMello CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS 7327,7339,7451,747 <br /> 7007,7111,7313 VV March Lane Stockton 95219 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 6110 Granica Ct. <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Stockton CA 95215 <br /> PHONE#1 209-986-1804, 209-931E''3800 APN# 071-140-01,02,07,08, LAND USE APPLICATION# <br /> ( 209) 915-8132 09,10, 11 <br /> PHONE#2T• BOS DISTRICT y LOCATION CODE <br /> ( 209 ) 915-8132 S <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORJoeMurphy CHECK if BILLINGADDRESSE] <br /> BUSINESS NAME PHONE# ExT' <br /> Dillon & Murphy 209 334-6613 317 <br /> HOME or MAILING ADDRESS FAX# <br /> 847 N. Cluff Avenue, Suite A2 (209 ) 334-0723 <br /> CITY Lodi STATE CA ZIP 95240 <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,ST L laws. <br /> APPLICANT'S SIGNATURE: DATE:_08/30/2022 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Ot7 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 samtime it is <br /> provided to me or my representative. "I P-4 <br /> TYPE OF SERVICE REQUESTED: SOj� Su i i-A6;I�I t /v Gnd IftA�e LoaG)Irl 54u <br /> COMMENTS: 4tlG 3 V <br /> SAN✓OqQu <br /> ?W 2 <br /> FJvv, /N <br /> yPLTy���OU T), <br /> ACCEPTED BY: ���f EMPLOYEE#: DATE: a <br /> ASSIGNED TO: / EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: SoZ PIE: a G a a <br /> Fee Amount: . c a Amount Pa IPZ Payment Date <br /> Payment Type C� Invoice# Check# .2-3622— Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />