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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Winery co I�� c) <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Lani Holdener <br /> FACILITY NAME <br /> SITE ADDRESSp E Peltier Road Acampo 95220 <br /> 7151 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 /> Linden CA. 95236 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 )481-5872 005-260-61 - C() () <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Joel Montano CHECK if BILLING ADDRESS El <br /> BUSINESS NAME PHONE# EXT. <br /> Dillon & Murphy 334-6613 >2 <br /> HOME Or MAILING ADDRESS FAX# <br /> P.O. Box 2180 ( ) <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 4:::�z Cvt:� DATE: November 11, 2019 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT O Staff <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 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: 17� SA, (�•UI,'- V" _ o /J rate, <br /> 5 <br /> H qRp 11.,.0 <br /> ACCEPTED BY: EMPLOYEE#: DATE: If <br /> ASSIGNED TO: EMPLOYEE M d DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: j PIE: O � <br /> Fee Amount: © Amount Paid Payment Date (J <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />