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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Avo& Nonna Machado, LP CHECK if BILLING ADDRESS E] <br /> FACILITY NAME <br /> —F— <br /> SITE ADDRESS 2696&2288 N. Murray Road Linden 95236 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 555 Street Number Street Name <br /> CITY STATE ZIP <br /> Linden CA 95236 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 601-5277 1105-100-20, 21 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Murphy CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Dillon & Murphy, c/o Joe Murphy 209 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 2180 ( ) <br /> CITY STATEZip <br /> Lodi CA 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 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: 1' 7-1 <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT EX Engineer <br /> If APPLICANT is not LtILLING PARTY 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 HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SAN J�OAQU//V i9 <br /> � <br /> ee) &Te�� pARTTA�Il' <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: r\ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E <br /> Fee Amount: 0 Amount Paid 30 T _ Payment Date 1 12-2—/ / <br /> Payment Type Invoice# Check# f a OS Received By: j <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />