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SAN JOAQUI N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FAaUTY ID# <br />SERVICE REQUEST# <br />sEp 30 ° <br />PHO E# EXT <br />Dillon & Murphy Civil Engineer <br />52��8584� <br />OWNER / OPERATOR <br />HOME Or MAILING ADDRESS <br />Nancy Butler and Salvador Rivera <br />CHECK If BILLING ADDRESS❑ <br />FACILITY NAME <br />ACCEPTED BY: ��) ' <br />3TEADDaEss 550 &598 <br />N <br />Hewitt Road <br />ASSIGNED TO: S <br />L! ^ ^ <br />95236 <br />Street Number <br />Direction <br />Street Name <br />SERacECODE: 3 <br />Cit <br />Zip Code <br />Howor MauNGADDRESs (If Different from Site Address) 550 <br />Hewitt Road <br />Street Number <br />Street Name <br />CITY 'QLIIGRZ�� f <br />STATE ZIP 95236 <br />l -`flAL� <br />CA <br />PHONE #1 EXT <br />APN # <br />LAND USE APPLICATION # <br />( 209) 652-2172 <br />093-030-63 <br />PA -2100084 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />Joel Montano <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />sEp 30 ° <br />PHO E# EXT <br />Dillon & Murphy Civil Engineer <br />209 334-6613 <br />HOME Or MAILING ADDRESS <br />�4 <br />FAX# <br />PO Box 2180 <br />ACCEPTED BY: ��) ' <br />( > <br />CITY Lodi <br />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 tome or my business as identified on thisform. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with ail SAN JOAQUI N <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPL I CANT'S SI GNATURE: ,lL-�' DATE: Uq /Z 9 /Z6Z <br />PROPERTY/ BUS NESS 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. P <br />TYPE OF SERVICEREC�JESTID: sc, ( �c.,}c7� ,I } �i/�CI <br />N, 11'tft LDfC'%jn' 1Ui�� kPY!(' ✓ Af! <br />sEp 30 ° <br />aw'1oA 2022 <br />H EIV�/ROU/N co <br />STH' NAY <br />�4 <br />ACCEPTED BY: ��) ' <br />EMPLOYEE #: <br />DATE. So .Z cD <br />ASSIGNED TO: S <br />EMPLOYEE #: <br />DATE:� <br />Date Service Completed (if already completed): <br />SERacECODE: 3 <br />P/E: 4� J� <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />L� <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />Project #2103 <br />