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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property ��;� ��:iY►1nu.� an R� FACILITY ID # CHECK If BILLING ADDRESS SERVICE REQUEST # ZCiiVie PHONE # EXT. Dillon & Murphy Engineering log 209 334-6613 OWNER / OPERATOR SAfVJOAQU At IRON/ �N FAX # John Dondero HENT MR N CHECK If BILLING ADDRESS FACILITY NAME STATE CA ZIP 95241 ASSIGNED TO: SITE ADDRESS 2658 DATE: J Drais Ave Stockton 95215 Street Number Direction P 1 E: �S Street Name Amount Paid Cit Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 1776 Check # i, N. Murray Road Street Number Street Name CITY STATE Zip Linden CA 95236 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 209) 401-9784 183-230-14 PHONE #2 EXT. BOS DISTRICT�� LOCATION CODE ( ) (•^(- CONTRACTOR / SERVICE REQUESTOR REQUESTOR ��;� ��:iY►1nu.� an R� Tristan Hartung CHECK If BILLING ADDRESS BUSINESS NAME ZCiiVie PHONE # EXT. Dillon & Murphy Engineering log 209 334-6613 HOME or MAILING ADDRESS SAfVJOAQU At IRON/ �N FAX # PO Box 2180 HENT MR N ( ) CITY Lodi STATE CA ZIP 95241 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Stan rds, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER❑ ( I OPERATOR/ MANAGER ❑ ' OTHER AUTHORIZED AGENT l IfAPPLICANT is not * BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: �� Y 1G,c G ✓1 r"� 1j �" 5.'��c,LF ��;� ��:iY►1nu.� an R� !� PAYAN COMMENTS: ZCiiVie log SAfVJOAQU At IRON/ �N HENT MR N ACCEPTED BY:��; j L �' EMPLOYEE #: DATE: �pp ly J rMEtl// ASSIGNED TO: EMPLOYEE #: DATE: J Date Service Completed (If already completed): SERVICE CODE: �? 3 P 1 E: �S Fee Amount: sb Amount Paid Payment Date & IX24 Payment Type Invoice # Check # i, Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003