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o7 <br /> SAN JOAQUki . COUNTY ENVIRONMENTAL HEALLTIi OEPARTMENT l { j <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Residential <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS ® <br /> JR and DK Investments LLC , c/o Janet Ramirez <br /> FACILITY NAME <br /> N/A <br /> SITE ADDRESS Mourfield Avenue Stockton 95206 <br /> 3510 Street Number Direction Street Name L City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) 4152 Feather River Road , Ste C <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95219 <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> ( 209 ) 598 - 1502 175- 150 - 51 <br /> PHONE #2 EXT • Ir <br /> ISTRICT LOCATION CODE <br /> ( 209 ) 472 - 0389 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRES <br /> BUSINESS NAME PHONE # Ex-r . <br /> Dillon & Murphy 209 334-6613 <br /> HOME or MAILING ADDRESS FAX # <br /> PO Box 2180 ( 209 - 34 -0723 <br /> CITY Lodi STATE CA 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, Standards ySTATE and FE L laws . <br /> APPLICANT ' S SIGNATURE : DATE : U <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / NYANAGER ❑ OTHER AUTHORIZED AGENT © {111Ar <br /> IfAPPLICANT 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 <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 /> ACCEPTED BY : EMPLOYEE # : DATE : <br /> ASSIGNED TO : EMPLOYEE # : DATE . <br /> Date Service Completed ( if already completed ) : SERVICE CODE : PIE : <br /> Fee Amount . Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48 -02 - 025 SR FORM ( Golden Rod) <br /> REVISED 11 / 17/2003 <br />