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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S� co301Q 1 a <br /> OWNER/OPERATOR <br /> Jeff Thompson CHECK If BILLING ADDRESSO <br /> FACILITY NAME <br /> SITE ADDRESS 20450,20600, N Davis Road95242 <br /> 20920 Lodi <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 837 Cypress Run <br /> SVeet Number Street Name <br /> CITY STATE ZIP <br /> Woodbridge CA 95258 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 747-5376 013-090-27, 28, 29, 30 & 31 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R QUE STI ORlon CHECK if BILLING ADDRESS El <br /> BUSINESS NAME PHONE# EXT. <br /> Dillon & Murphy 209 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> 847 N. Cluff Ave., Ste A2 (209 )334-0723 <br /> CITY Lodi STATE CA ZIP 95240 <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,Standards,STATE and F DE s. <br /> APPLICANT'S SIGNATURE: ��— DATE; May 14, 2019 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Engineer <br /> If APPL/CANT 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 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: 91 <br /> �G <br /> COMMENTS: <br /> cejve0 <br /> SAN 14 ?019 <br /> NTHaONMENTUN7y <br /> AI <br /> ACCEPTED BY: EMPLOYEE M r <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 67 v P 1 E: <br /> Fee Amount: �J� Amount Paid 3o 4. O U Payme Date 9/14 I <br /> Payment Type ✓ Invoice# Check# 141-7 D Received By: L6 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />