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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property ( FACILITY ID # Bradley Handle SERVICE REQUEST # Residential BUSINESS NAME Dillon & Murphy F Jp�QUIN PHONE# 0'�q-I,- I,-OWNER/ OWNER/OPERATOR 209 M & A Realty Investments HOME Or MAILING ADDRESS CHECK if BILLING ADDRESS❑ FACILITY NAME ASSIGNED TO: ; f b PO Box 2180 Lodi, CA 95241 N/A ( 209) 334-0723 SITE ADDRESS 309 SLos An eles Ave g Stockton 95203 Street Number Direction Street Name 3o , 0D CI Code HOME or MAILING ADDRESS (If Different from Site Address) 1731 Check # l W. Harding Way Street Number Street Name CITY Stockton STATE ZIP CA 95203 PHONE #') EXT. PN # LAND USE APPLICATION # (209) 559-3509 7145-063-25 PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR ( COMMENTS: Bradley Handle CHECK If BILLING ADDRESS EJ BUSINESS NAME Dillon & Murphy F Jp�QUIN PHONE# EXT. 209 334-6613 HOME Or MAILING ADDRESS EMPLOYEE M FAX# ASSIGNED TO: ; f b PO Box 2180 Lodi, CA 95241 EMPLOYEE #: k/ ( 209) 334-0723 CITY Lodi STATE CA ZIP 95241 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: �' DATE: PROPERTA' / BDSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT LJ pC0 t J J IfAPPLICflNT is not the BILLINGPARTr, proof of authorization to sign is required —�i Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representativ<—/�--` , #%- TYPE- TYPE OF SERVICE REQUESTED: _ ( COMMENTS: en SqN F Jp�QUIN N� -H DEpM �� 7Y ACCEPTED BY: EMPLOYEE M DATE: ASSIGNED TO: ; f b EMPLOYEE #: k/ DATE: � Date Service Completed (if already completed): SERVICE CODE: P/ E: i Fee Amount: yS Amount Pai 3o , 0D Payment Date Z Payment Type Invoice # Check # l Rece ed By: ue EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003