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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (S9-001q1 (P�? <br /> OWNER/OPERATOR Chris Knoll <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 9296 E. State Highway 12 Lodi 95240 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 334-0750 051-120-56 PA-1800064 <br /> PHONE#2 EXT. BOS DISTRICT--7LOCATION CODE <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR Mike Toy CHECK if BILLING ADDRESS <br /> BUSINESS NAME Dillon&Murphy PHONE# EXT. <br /> 209 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 2180 (209 ) 334-0723 <br /> CITY Lodi STATE CA ZIP 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 or <br /> 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, STATE and FEDE laws. <br /> APPLICANT'S SIGNATURE: -- DATE: 10-2-18 <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessmenp ation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is pr0�lf{� <br /> my representative. //�� <br /> TYPE OF SERVICE REQUESTED: sw-&�StOdy om( Oii -8 `v <br /> COMMENTS: 1/ � <br /> 7'?101 <br /> HFNVgQVIN <br /> ZTkbp <br /> roF �IV <br /> ACCEPTED BY: Oil EMPLOYEE EMPLOYEE#: DATE: 1O �� <br /> ASSIGNED TO: v(vo t EMPLOYEE#: DATE: ` /1 ( p6 <br /> Date Service Complete (if already completed): SERVICE CODE: 52, PIE: z(Q 0 <br /> Fee Amount: ?Jv Amount Pai 30 6� Payment Date71 101 q I <br /> Payment Type Invoice# Check# �0 f Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />