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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property -T iJ FACILITY ID # SERVICE REQUEFS�T, # BUSINESS NAME ACCEPTED BY: L Z PHONE # EXT• Dillon & Murphy Engineering OWNER/ OPERATOR HOME or MAILING ADDRESS CHECK if BILLING E] John Dondero PO Box 2180 ADDRESS FACILITY NAME CITY Lodi STATE CA ZIP 95241 SITE ADDRESS 2658 Fee Amount: Amount P ' Drais Ave Payment Date {� Stockton 95215 Street Number Direction Street Name citv Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 1776N. 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 ( ) 11 CIA G CONTRACTOR / SERVICE REQUESTOR REQUESTOR iJ Tristan Hartung CHECK if BILLING ADDRESS BUSINESS NAME ACCEPTED BY: L Z PHONE # EXT• Dillon & Murphy Engineering 209 334-6613 HOME or MAILING ADDRESS FAX# PO Box 2180 DATE: C r d J ( ) 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, Standards, STATE and FEDERAL la s. APPLICANT'S SIGNATURE: DATE: 4L4SEP Za2( PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER OTHER AUTHORIZED AGENT l� CA,, If APPLICANT is not the BILLING PARTY proof 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. b.. TYPE OF SERVICE REQUESTED: 1/7 iJ COMMENTS: Stp' �o y 2D , 21 EAfv/,yQu/N HF,gLTN p� 4f Nolj tY ACCEPTED BY: L Z EMPLOYEE #: DATE: G / ASSIGNED TO: EMPLOYEE #: DATE: C r d J Date Service Completed (if already completed): SERVICE CODE: S a P I E. a 6Oo? Fee Amount: Amount P ' & / �� Payment Date {� Payment Type Invoice # Check # Recei` d By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003