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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST If <br /> 5 -7 <br /> OWNER/OPERATOR <br /> Brent Workman CHECKIf BILLING ADORESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS N Acampo 95220 <br /> 21379 Street Number Direction Mann Road Street Name city Zi Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# <br /> (209 ) 810-4521 172gbo9 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# Em <br /> Dillon&Murphy, Engineering 209 334-6613 <br /> HOME Or MAILING ADDRESS FAX# <br /> PO Box 2180 (209 ) 334-0723 <br /> CITY Lodi STATE OA ZIP 95241 <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 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,Stan STATE and F RALws. <br /> APPLICANT'S SIGNATURE: DATE: (0��� <br /> PROPERTY/BUSINEss OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® <br /> IrAPPLICANT is no t BILLING PARTY proof of authorizadon 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 HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. /J <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> /l�z0//-7 3oer A-h Sc Od,-RECEIVED <br /> tll�s�r7 d� ,�,v. c�� <br /> OCT 2 6 2011 <br /> SAN JOAQ NMCOUNTY <br /> ENTAL <br /> ACCEPTED BY: EMPLOYEE#: HEALTH DEP TE:/0 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed already Completed): SERVICE CODE: 5�3 PI E: <br /> Fee Amount: Amount Paid �� Payment Date �� A6 , <br /> Payment Type Invoice# Check# 4; - Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />