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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> e-'-N\ <br /> V <br /> OWNER/OPERATOR <br /> Terry Tarditi <br /> CHECK if BILLING ADDR SS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 11396 N St. Rt. 99 Frontage Road Lodi 95240 <br /> Street Number I Direction Street Name City L Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'l EXT. APN# LAND USE APPLICATION# <br /> ( 209) 931-6000 059-260-10 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK if BILLING ADDRESS <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: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL Hml,''li D1:hARTMENr hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 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, STAT I's and I'Iil)BRAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPFRTY/BUSINESS OWNER OPERATOR/MANAGER ❑ O'rlll?R Atl"I'IloR171?D A(;EN'I'L1a Civil Engineer <br /> 11'111'P1,i(.'IN''T is not the BILLING I)ARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 HIiN;rll DIiPARTMLNT as soon as it is available and at the sai> s <br /> provided to me or my representative. NT <br /> TYPE OF SERVICE REQUESTED: G D <br /> COMMENTS: M2, 4 <br /> SAN NV/R pit N CO <br /> ' gLTH DE E�IVTY <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 2— <br /> ASSIGNED <br /> ASSIGNED TO: \_ ^ A EMPLOYEE#: DATE: <br /> Date Service Completed (If already Completed): SERVICE CODE: L� PIE: 03 <br /> Fee Amount: �-uk W I <br /> Amount Pal 3Z D� Payment Date �D <br /> Payment Type 1119 Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />