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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 /> Chris& Diane Knolls CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 9296 E. State Route 12 Lodi 95240 <br /> Street Number Direction Street Name C ity 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 LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Mike Toy CHECK If BILLING ADDRESS <br /> BUSINESS NAME Dillon & Murphy PHONE# EXT. <br /> 2091 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 2180 <br /> (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 F Ws. <br /> APPLICANT'S SIGNATURE: DATE: r0— <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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, 1, the owner or operator of the propeXty located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/sit �t,ninformation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same,�r�. lC��`to me or <br /> my representative. dna M My <br /> TYPE OF SERVICE REQUESTED: Soil Suitability Study O <br /> COMMENTS: .ISM JO <br /> AQUIN C <br /> NDN H D I ��rY <br /> ACCEPTED BY: I qua �(�I�,W" EMPLOYEE#: DATE: V <br /> 'W V 1� <br /> ASSIGNED TO: WOO " EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 52� P1 E: <br /> Fee Amount: 3c� Amount Pai Payment Date <br /> Payment Type CJ Invoice# Check# 1 b/s Received d4L <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />