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PA 10 0256 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Residential :5 RG 0 S4 417 <br /> OWNER / OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Ivan Rico <br /> FACILITY NAME <br /> N /A <br /> SITE ADDRESS 55 <br /> N Olive Avenue Stockton 95215 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING /A--DDRESS ( If Different from Site Address ) I rc <br /> L) 60i I IZ7 Street Number Street Name <br /> CITY STATE � � ZIP <br /> < =� � � -0 <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 209 ' 915- 1359 157 - 210 - 33 <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS ❑ <br /> James Selke <br /> BUSINESS NAME PHONE # ExT. <br /> Dillon & Murphy 209 334- 6613 <br /> HOMEOr MAILING ADDRESS FAx # <br /> PO Box 2180 , ( 209 ) 334 -0723 <br /> CITY Lodi STATE CA ZIP 95241 <br /> BILLING ACKNOWLEDGEMENT : I , 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, STAB DERAL laws . <br /> APPLICANT ' S SIGNATURE : DATE : olo.5/aw <br /> PROPERTY / BUSINESS OWNER ❑ r—OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT 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 environmentaUsite 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 : Rev ') <br /> COMMENTS : � <br /> OCT 2 <br /> s doq <br /> '920 <br /> 21 <br /> QU/ <br /> h FN�IRp N Co <br /> STH J rN FNpia T�N�• <br /> ZA <br /> ACCEPTED BY : j2 �J EMPLOYEE # : DATE :MMMMMM <br /> ASSIGNED Tom � J EMPLOYEE # : DATE : <br /> Date Service Completed ( if already completed ) : SERVICE CODE : S P 1 E : <br /> Fee Amount : 3 0L� Amount Paid �0 Payment Date I O � 2. 9 ( 2 j <br /> Payment Type Invoice # Check # MMMMMMMReceived By : <br /> EHD 48 - 02-025 SR FORM (Golden Rod) <br /> REVISED 11 / 17/2003 <br />