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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 9� 0C� -795c��' <br /> OWNER I OPERATOR <br /> Octavio Medina <br /> CHECK If BILLING ADDRESS O <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 824S. Hinkle Avenue Stockton 95215 <br /> Street Number Direction Street ame cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 2522 tuber Grand Canal Blvj,Nam 4 <br /> CITY STATE ZIP <br /> Stockton CA 95207 <br /> PHONE#1 ExT. APN# LANDUSE APPLICATION# <br /> ( 209 ) 470-9028 157-253-13 <br /> PHONE in Fir. BOS DISTRICT LOCATION CODE <br /> 1 1 G C' <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR f BILLING ADDRES <br /> Joe Murphy CHECK I <br /> BUSINESS NAME PHONE# Ev. <br /> Dillon & Murphy 209 1 334-6613 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE.:/ Zi li7-lcb <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT DO Engineer <br /> /fAPPLICANT is not e ILLING 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 t0 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. AYMET <br /> TYPE OF SERVICE REQUESTED: QCR P.r � N 1 <br /> COMMENTS: <br /> AUG 2 3 2018 <br /> SAN JOAQUIN COUNT) <br /> ENVIRONMEt I t t � <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: SPA EMPLOYEE#: DATE: .a <br /> ASSIGNED TO: Won r—,I` EMPLOYEE#: DATE: <br /> Date Service Completed ((n already completed): SERVICE CODE: G,23 PIE: <br /> (P 0 sJ <br /> Fee Amount: O Amount Pai 'soTL6b Payment Date O <br /> Payment Type Invoice# Check# 1 975-6 —Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />